Sie sind auf Seite 1von 41

CEREBROVASCULAR DISEASE:

1.
2. In patient with tandem severe bulb stenosis and intracranial carotid disease, the bulb is treated first. The intracranial
disease is only treated if neurologic symptoms persist.
3. GALA trial: No significant difference in stroke, MI or death in GA vs LA during CEA. Main benefit of LA is better neuro
monitoring and thus better selective shunting.
4. Eversion technique: Ideal for patients with coils and kinks of the carotid artery
5. Better distal ICA exposure can be obtained by: Medial ICA mobilization, nasotracheal intubation (since mouth is
closed), anterior mandible subluxation, resection styloid process or division of posterior belly of digastric
6. If neurologic deficit after surgery, and no completion study was done (duplex or angio)  Mandatory re-exploration
a. If completion study shows flow  symptoms likely secondary to embolization or ischemia, thus neuro-
rescue should be done with angio +/- lysis or extraction
7. NASCET:
a. CEA benefit if Symptomatic and >50%
b. If >70% stenosis, symptomatic CEA benefit of 17% stroke reduction at 2-years and persists for 8 years
8. ACAS: Showed CEA reduction of stroke by 5.9% at 5-years in Asymptomatic patients if >60% stenosis
9. Risk factors for hyperperfusion syndrome: Uncontrolled HTN at baseline, High-grade contralateral stenosis, urgent CEA
surgery and recent ipsilateral stroke, History of contrateral CEA
a. Has high mortality, and pressure should be maintained lower than 140/80 post-op
10. Stump Syndrome: Complete ICA occlusion w/ ipsilateral neurologic symptoms
a. Treat with CCA and ECA endarterectomy patch angioplasty with transection of ICA
b. In this condition ICA stump acts as reservoir for fresh thrombus and embolizes up the ECA and into the brain
via retrograde flow from the supraorbital and infraorbital vessels
11. Radiation Carotid Disease:
a. Unusual anatomic locations, and tend to be extensive rather than focal
b. Show up months to years after radiation
c. Not well defined planes, thus increased cranial nerve injury
12. Glossopharyngeal nerve injury  Leads to pulmonary aspiration
a. Injury risk with division of posterior belly of digastric, thus should only taken down a few fibers at a time
without Electrocautery
13. ICA dissection after CEA: can present with high-resistance doppler w/ minimal diastolic flow
a. Managed w/ reclamping and revising the flap at the distal endpoint
i. If flap is distal, stenting should be considered
b. **If spasm  treated with nitroglycerin
c. **If traumatic dissection  anticoagulation preferred
14. For bilateral CAS, the symptomatic side should be treated first
15. Traumatic carotid dissection  Anticoagulation
a. Antiplatelet and Heparin are equally effective, however if patient has bleeding risk avoid heparin and use
aspirin
b. **However, if patient has neurologic DEFICITS  Operative management
16. Verterbrobasilar insuffiency  Presents as ataxia
a. If concurrent symptomatic CAS, the CAS should be treated first since it may open up collateral that supply
the vertebral system
17. CREST:
a. Randomized symptomatic and asymptomatic to either stent or CEA
b. Combined endpoints (stroke, death and MI) showed equivalence
c. Individually the stroke endpoint was higher in stent
18. In FMD of ICA, initial treatment is with antiplatelet therapy.
a. If fails  Intervention with PTA
b. **Open surgery avoided since disease commonly extends to the skull base or higher
c. **Stents should be avoided unless there is an aneurysm or dissection
19. Tandem CA lesions:
a. Treat the bifurcation disease as a separate process from the more distal lesion
i. Thus, either CEA or stent for bifurcation depending on which is better for patient; and, ASA+Statin
for the distal lesion
20. Cerebral hyperperfusion syndrome:
a. Can manifest after severe ipsilateral headache after CEA from severe stenosis
b. Risk of intracranial hemorrhage and stroke
c. Pain control and neuro-checks for mild headache
d. If severe  Non-con CT to rule our hemorrhage and aggressive BP control
e. **Even if no headache, and BP is elevate  aggressive BP control
21. If concurrent severe CAS and asymptomatic intracranial aneurysm <8mm  Treat CAS first
a. Only symptomatic of >8mm intracranial aneurysms are treated
22. Reversed vertebral flow is incidental finding in carotid duplex, which can be caused by steal from proximal subclavian
stenosis
a. Treat only if symptomatic (however, a single syncope episode in elder person is not convincing enough for
intervention and the presumed subclavian stenosis should not be intervened on)
23. After stroke if NO hemorrhagic component, you should intervene when the neuro deficits have resolved and they are
clinically stable, ideally 3-14 days after the initial presenting symptom
a. If residual hemiplegia, they are not candidates for intervention
24. Open repair of Vertebral Artery stenosis  Risk of Horner’s most common
25. Subclavian Stenosis:
a. Early systolic deceleration in vertebral artery is most suggestive of subclavian stenosis
b. Monophasic flow in distal subclavian is likely due to a total occlusion, not a stenosis
c. **Tardus parvus (decreased systolic amplitude, called pulsus parvus, and prolonged systolic acceleration,
called pulsus tardus) is associated with significant arterial stenosis
26. Patient on dialysis have high perioperative and long-term stroke and death rates after carotid intervention for
asymptomatic stenosis
27. CEA should be performed 3-14 days after appearance of symptoms of brain ischemia
28. ASA w/ Clopidogrel provides better stroke prevention than ASA alone
29. Early stroke management:
a. Give early lytic therapy
b. Lytic therapy only beneficial up to the 4.5 hour mark after symptom onset
c. Lytic therapy should be given even if endovascular symptoms are being considered
30. History of contralateral CEA gives risk for Cerebral hyperperfusion syndrome
a. Increased time between the two surgeries decreases this risk
31. If arterial trauma from accidental large bore catheter placement (7F or higher), open surgical exploration and repair is
warranted
a. Only use stenting if injury in area with difficult exposure
b. Closure devices should be avoided since this is an off-label use
c. Pull-and-pressure avoided since higher risk of AV-Fistula formation, stroke, airway compromise and
bleeding
32. In the setting of ipsilateral stroke with complete occlusion of the ICA, consider ECA collateral source
a. Perform and external carotid endarterectomy. When this is done, must oversew proximal stump of the ICA
33. Carotid Body Tumor:
a. First step is biochemical evaluation of 24hr-metanephrines and catecholamines
b. Ease of resection can be predicted by Shamblin classification of the tumor
34. In traumatic ICA dissections, initial treatment is antiplatelet/anticoagulation
a. If fails  Endovascular or open surgical therapy
35. FMD is associated with “string on beads” and HTN secondary to renal involvement
36. CCA pseudoaneurysms should be managed with resection and interposition using reversed saphenous. Given the size
mismatch of the distal and proximal CCA, stenting is not very feasible
37. Accidental arterial cannulation with large bore catheter should be managed with surgical exploration, however prior to
this a CTA must be obtained for operative planning and to assess for thrombus.
a. If the catheter was already removed, duplex should be performed to evaluate for bleeding, thrombus or
pseudoaneurysm formation
38. Markers for adequate cerebral perfusion during CEA
a. Stump pressures, should be >40mmHg
b. Awake neuro monitoring
c. EEG suppression
d. Indications for shunting: Contralateral carotid artery occlusion
39. During CEA, the carotid sinus can cause bradycardia and hypotension since it innervates the nerve of Hering, which is
branch of glossopharyngeal
a. To treat, can inject 1-2cc lidocaine in tissue near sinus
i. However, in severe bradycardia, IV-Atropine should be given. Vasopressors should also be given if
severe hypotension
40. Takaysu and Giant Cell Arteritis  Involve large vessels
a. Takayasu:
i. Younger females
ii. Affects aorta and primary branches
b. GCA:
i. Older, equal gender distribution
ii. Affects distal arterial segments
c. Intervention is not warranted during active inflammatory phase (myalgia, elevated ESR, constitutional
symptoms)
i. Initially treat with steroids to limit disease progression
ii. If resistant to steroids  use other immunosuppressants like azathioprine, methotrexate,
cyclophosphamide; if these also fail  Anti-TNF (Infliximab)
d. When active disease is quiescent, treat any occlusive areas with open surgery
41. With carotid-subclavian bypass  Risk of ipsilateral phrenic nerve injury
a. Phrenic nerve courses the anterior scalene, and lies between the subclavian vein (anterior) and artery
(Posterior)
42. In patients with TA or GCA, after steroids they enter the quiescent period
a. In TA the most durable and appropriate revascularization treatment is a bypass, from the ascending aorta
which is usually not involved in TA
43. FMD: Commonly Renal and carotid but can also affect others
a. “string-of-beads” is due to Medial Fibroplasia, and is the most common type
b. The other types:
i. Intimal fibroplasia  Single, concentric stenosis or long tapering of the renal and carotid arteries
ii. Medial Hyperplasia  Single, concentric stenosis or long tapering of the renal and carotid arteries
iii. Adventitial Hyperplasia  Least common; Seen as localized stenosis
iv. Perimedial Dysplasia  Affects renals only and associated with macroaneurysms
44. Carotid artery dissection: Classic presentation is facial pain, headache and partial Horner’s
45. Coronary-subclavian steal syndrome:
a. Treat with carotid subclavian bypass
b. Short prosthetics have better patency in the supraclavicular area
46. After CEA, the Hypoglossal and Vagus nerves are most commony affected
a. Vagus  Vocal chord, Hoarsness
b. Less commonly the marginal mandibular affected  Ipsilateral face droop
i. Usually to cephalad retraction of the mandible
47. Vertebral Transposition: Can be considered if vertebral disease in setting of mild carotid stenosis in patient with
dizziness and unsteadiness
i. **This is because if the ICA has significant disease, after CEA it would open more collaterals
b. Technical consideration: mobilize vertebral veins and avoid sympathetic ganglion
c. Other open methods:
i. Ostial lesion or inflow stsenosis  Transposition or endarterectomy
ii. Distal V2/V3 lesion  Bypass
48. During a CEA, the best way to perform neurologic monitoring is with awake neuro exams
a. EEG has higher false positives
49. For acute ICA dissections, if asymptomatic  Antiplatelet
a. If symptomatic  Surgical repair
50. Positional Posterior Insufficiency: Bow-Hunter syndrome
a. Caused by vessel compression from hypertrophic osteophyte, cervical spondylosis, fibrous band or thick
alantoaxial membrane
b. Treatment: cervical fixation, osseous or fibrous tissue decompression, or bypass if concurrent
atherosclerotic disease
i. Use venous conduit
ii. **If concurrent ICA significant stenosis  Treat with CEA instead

UPPER EXTREMITY VASCULAR DISEASE

1. Dysphagia Lusoria:
a. Commonly due to aberrant right subclavian artery, that goes posterior to esophagus
b. Treatment is transposition on to the RCA; however, this procedure can be combined w/ TEVAR to cover the
origin of the RCA
c. The aberrant right subclavian is predisposed to aneurysm degeneration
2. Subclavian steal: with proximal subclavian stenosis, there is reversal of flow from ipsilateral vertebral
a. Most commonly atherosclerosis, however can be due to thoracic outlet or arteritis
3. In a patient with acute upper/lower limb ischemia, embolus from cardiac source is most common. This is even in the
setting of no ongoing arrhythmia in the patient
4. Thromboagitis Obliterans: Imaging shows thrombosis of small and medium sized distal to the brachial and popliteal
arteries
a. Diagnosis of exclusion, thus patients do not have other causes like atherosclerosis, embolism or traumatic
injury
b. Treatment: Smoking cessation; Iloprost is prostacyclin that shows some improvement
5. Anatomic location of subclavian artery makes it hard to apply manual pressure
a. Distal subclavian and axillary artery can be exposed via infraclavicle incision
b. Proximal subclavian exposure requires median sternotomy
6. Brachial sheath hematoma: Even a small hematoma my cause significant neurologic complications
7. Arterial TOS: Most common is subclavian artery compression
a. Axillary artery (Uncommon variant): Due to compression by humeral head
i. In this area the axillary artery is surrounded by overlying fascia, branch vessels (Humeral
Circumflex and subscapular arteries), and the pectoralis minor; all these trap the artery
ii. Repetitive trauma by overhand throwing from compression causes intimal hyperplasia, aneurysm
formation with mural thrombus and/or branch vessel aneurysms associated with embolization
iii. Diagnosis: Non-invasive brachial-brachial indexes and forearm/digital waveforms
iv. Treatment:
1. Thrombolysis can be useful prior to proceeding with vascular reconstruction especially
in setting of acute finger embolization
2. Reconstruction and ligation of aneurysmal branches
8. Venous TOS: Paget-Schroeder Syndrome, or Effort vein thrombosis
a. Treatment: Thrombolysis followed by surgical decompression (1st rib resection and division of subclavius
tendon)
i. Delay of surgery risks re-thrombosis and increased scar formation
ii. **Avoid stents since high risk of fracture
9. Raynaud’s:
a. Primary or secondary (Rheumatologic [scleroderma, SLE], Hematologic [cryoglobulin, Paraneoplastic],
Neurologic [Carpal tunnel], Drug [Ergotamine], or Vascular Disease [Smoking])
b. Treatment:
i. Trigger avoidance, Smoking cessation, Avoid Caffiene
ii. Medical: Low-dose sustained release CCB {Nifedipine, Amlodipine, Felodipine}
1. Alternatives: Sildenafil, Topical Nitrates, ARBs or SSRIs
a. **Used if fail CCB or are contraindicated
10. Thrombolysis:
a. Absolute contraindications: Active bleeding, Recent head injury, Thrombocytopenia, recent spinal Surgery
11. Acute Upper Limb Ischemia: Start with systemic Heparin and Thrombectomy
12. Hypothenar Hammer Syndrome:
a. Due to repeated blunt trauma
b. Ulnar artery branches into the deep palmar and superficial palmar arch
i. The superficial branch crosses over the hamate and thus can be injured with repetitive
hypothenar trauma
13. Cervical Rib:
a. Can occur in some people. Causes subclavian artery compression with post-stenotic dilatation (appearing as
pulsatile mass).
b. The cervical rib can attach to the 1st rib directly or by a fibrous band
c. Although a cervical rib can be removed via transaxillary approach, in cases where the subclavian artery is
involved a supraclavicular approach should be taken to allow for vessel reconstruction.
i. The vessel should be reconstructed since risk of aneurysmal degeneration, thrombosis and distal
embolization
14. For upper extremity DVT secondary to venous TOS, if recent DVT thrombolytics should be given to prevent post-
thrombotic syndrome
a. Furthermore, rib resection should not be delayed more than a few weeks
15. Ligation of the Left Innominate vein can facilitate exposure of the aortic arch or mediastinum during resection of large
tumors
a. After ligation return occurs via collateral systems: Azygous/Hemiazygous, Internal Mammary, Lateral
Thoracic, Superficial Thoracoabdominal, Vertebral Plexus and Transverse Sinus veins
16. Hypothenar Hammer Syndrome:
a. Can cause ulnar artery aneurysms. Typically, will have corkscrew appearance due to intraluminal thrombus.
b. Repair should be done with reversed vein conduit
c. In cases of aneurysm thrombosis or embolization, thrombolytic therapy improved symptoms prior to
arterial replacement
17. When radial artery thrombosis in the setting of clinical ischemic changes is diagnosed, the vascular surgeon must
determine whether the ischemia is severe enough to warrant surgical intervention versus conservative management
with observation and anticoagulation.
18. Raynauds Medications:
a. Calcium channel blockers have been shown to decrease the frequency and severity of attacks in most
people with Raynaud's phenomenon. Examples include nifedipine (Procardia), amlodipine (Norvasc) and
felodipine. Alpha blockers help to ameliorate the actions of circulating norepinephrine. Examples include
prazosin (Minipress) and doxazosin (Cardura). Direct vasodilators are sometimes used in these patients.
Topical nitroglycerin cream may be applied to the base of the fingers in extreme cases. Examples include
losartan (Cozaar), sildenafil (Viagra), or fluoxetine (Prozac). Prostaglandins have also been used with some
success. Phosphodiesterase type V inhibitors are also being used successfully in patients with severe
Raynaud’s phenomenon, and bosentan (an endothelin-1 receptor antagonist) for prevention of recurrent
phenomenon on an increasing basis. Drugs to avoid include beta blockers and over the counter medications
such as pseudoephedrine.
19. Endovascular is primary intervention for patients with non-malignant SVC occlusion
a. However, this may require repeat interventions. This does not affect future open surgical reconstructions.
b. Surgical treatment of benign SVC syndrome is effective over long term, but may require endovascular
means to maintain graft patency
i. Spiral-saphenous vein is conduit of choice
20. Type-3 Supracondylar fracture gives risk of arterial occlusion
a. Risk of Volkmann’s contracture resulting in permanent flexion and claw-deformity of hand and fingers
b. Brachial artery may get pinched or thrombosed
c. Treatment: Orthopedic reduction followed by neuro-vascular exams
i. If pulse does not return  operative exploration
21. Raynaud’s: White (ischemia)  Blue (Cyanosis)  Red (Reperfusion)
a. Primary Raynaud’s does NOT progress to tissue loss and is benign, since reversible vasospasm
22. Quadrilateral Space:
a. Bordered by teres minor superiorly, humeral shaft laterally, teres major inferiorly and long head of triceps
medially.
b. Posterior humeral circumflex artery and axillary nerve run through here
c. Compression of the artery occurs when arm is Abducted and externally rotated
d. Chronic compression in athletes leads to aneurysm or occlusion
23. Cervical Rib:
a. More common in females
b. In some cases can be attached to the first rib (pseudoarthrosis)
i. In this case both the cervical and first rib should be removed via supraclavicular approach
c. Cervical ribs lie between the middle scalene and thus narrow the space in the scalene triangle  Pushes
nerve roots and subclavian artery
d. Approaches for TOS decompression:
i. Supraclavicular:
1. Allows visualization of cervical and first rib
2. Allows for vessel reconstruction
ii. Transaxillary: Allows complete first rib visualization
1. Not suitable if visual reconstruction needed
2. Not able to resect cervical rib
24. PICC lines have high rate of DVT. Subclavian vein catheters have higher rate of central stenosis compare to Internal
Jugular.
a. PICC and Subclavian catheters should be avoided in renal patients
25. If patient develops DVT secondary to a catheter used for long-term medications, DO NOT REMOVE IT if it it working
well. Instead, treat with therapeutic anticoagulation as long as it remains in place.
a. Removing the catheter and placing it elsewhere will give a very high risk of DVT in another location
26. Subclavian artery exposure/intervention risks:
a. Open surgical approaches generally require exposure of the supraclavicular fossa and brachial plexus, but
the risk of major nerve injury after supraclavicular dissection is low. The internal mammary artery will need
to be managed in this case, and can be ligated with minimal risk, provided it does not serve as inflow for a
coronary bypass or reconstructive myocutaneous muscle flap. Although subclavian aneurysms may present
with symptoms related to embolization, risk of procedure-related embolization can be reduced through
intra-operative anticoagulation and obtaining distal control before aneurysm manipulation. Laterality of the
dominant vertebral artery is a significant anatomic consideration for this patient because it would affect
stroke risk associated with ligation or endovascular exclusion versus preservation.
27. Proximal subclavian stenosis:
a. More common on left
b. If treated endovascular, most commonly done via PTA and balloon-expandable stent to allow precision
deployment to preserve vertebral and internal mammary arteries
28. Acute plaque rupture can present with worsening pain in digits with blue discoloration
a. This can occur with or without distal embolization
29. Aberrant right subclavian goes posterior to the esophagus
a. It has risk of aneurysmal dilation and progresses to dysphagia
b. Treat with proximal ligation and transposition to the carotid
30. In the setting of normal pulses, iatogenic soft tissue injury should be treated with non-invasive vascular testing and
local wound care
a. Example includes Amiodarone infiltration related skin necrosis
31. Primary Raynauds:
a. Treat with cold avoidance, if fails  Nifedipine and Losartan
32. Thoracic outlet includes the Scalene Triangle, Costoclavicular Space and Pectoralis Minor Space
a. Scalene triangle commonly compresses the brachial plexus
b. If Cervical rib and anomalous first rib they also compress the brachial plexus in the scalene triangle
c. Costoclavicular space is between the first rib and clavicle. Subclavian vein, subclavian artery and brachial
plexus go through here. However, it is most common site for subclavian vein compression
33. Abberant right subclavian: Associated with non-recurrent right laryngeal nerve
34. Neurogenic TOS: Most common form
a. Brachial plexus comes from C5-T1 nerve roots
b. Most commonly compressed at the scalene triangle
35. Primary Raynauds: Initial treatment should include antiplatelet and CCB
36. In patient that have steal immediately post-op after AVF placement, the best initial option is ligation. The other
options, Proximalization, Revision using distal inflow, and distal revascularization and interval ligation, should be
consider later.
37. Arterial TOS with subclavian artery aneurysm:
a. Decompression of TOS, Removal of Embolic source (either via bypass or aneursymectomy) and
revacularization
38. Axillary artery and brachial plexus travel together. Bleeding from artery travels along a rigid sheath and compresses
the nerve. Sensory deficit is noted first.
a. One should have high index of suspicion if evaluating axillary sheath hematoma since it may not be
apparent on physical exam.
b. Avoid diagnostic testing since delay treatment. Proceed to OR for decompression.
39. In patients with LIMA steal from CABG heart and proximal subclavian stenosis. Treat with either stent or Carotid-
Subclavian bypass.
a. A carotid-subclavian transposition would require proximal clamping which would give cardiac ischemia
during the clamp time
40. Left subclavian transposition to common carotid performed via a transverse supraclavicular incision. The incision is
made over the two heads of the SCM. After the Platysma is cut through, the dissection is carried down to the two
heads of the SCM.
a. Thoracic duct and vertebral vein are ligated
b. Omohyoid muscle is divided to improve exposure of the proximal subclavian artery and origin of the
vertebral artery
c. Anterior scalene is not divided since the subclavian is ligated proximally
41. Access related pseudoaneurysms that give nerve compression symptoms need open surgical decompression
42. Trapdoor Incision: Transverse Anterior thoracotomy w/ partial superior median sternotomy and left supraclavicular
incision
43. The proximal axillary artery can be exposed fraccom an Infraclavicular incision
a. **For upper extremity bypass, reversed saphenous is the conduit of choice, especially in a contaminated
field
44. Buerger’s Disease:
a. Small/Medium sized vessels
b. Distal upper and lower extremities
i. Always involves multiple limbs, thus, if only one limb is involved consider and alternative diagnosis
c. Segmental thrombotic occlusions w/ chronic arterial inflammation
d. Arteriography shows occlusion of the distal small/medium sized arteries with corkscrew appearance of
collaterals
45. Goblet Sign: Splaying of the carotid bifurcation suggestive of carotid body tumor
a. **Subclavian to carotid transposition is contraindicated in patient with LIMA CABG
46. After radial artery access, if artery becomes thrombosed, treat with short-term course of anticoagulation
47. Subclavian artery embolus: Thrombolysis is contraindicated since risk of vertebral embolization
a. Should be treated with surgical Thrombectomy via supraclavicular approach
48. Cervical Rib TOS:
a. Repetitive trauma to subclavian artery during arm motion results in aneurysmal degeneration and thrombus
formation
b. Incidence: Arterial TOS << Venous TOS <<< Neurogenic TOS
49. In patient with TOS and a cervical rib, resection of the rib is the most durable option
50. For Takayasu, surgery should only be done when disease is quiescent. The erythrocyte sedimentation rate is usually
elevated during the active phase of Takayasu's arteritis and may normalize once the disease becomes quiescent. A
normal erythrocyte sedimentation rate, afebrile state, and lack of vessel tenderness do not always indicate disease
quiescence.

DIALYSIS ACCESS

1. AVF has greater patency than grafts. Accesses with larger inflow arteries have better patency than smaller inflow.
Access with larger outflow vessels have better patency than smaller veins.
2. HeRO Graft: Used in patients with central venous stenosis
a. The stenosis should be able to be crossed with a wire and catheter
b. Contraindicated in low EF, Active infection or brachial arteries < 3mm
3. Veins for outflow should be 3mm or larger for successful maturation
4. Small artery <2mm is most often the reason for failed AVF maturation
5. Preoperative vein mapping leads to improved initial failure rates, but the primary patency at 1-year is no different
6. Maturation: 600cc/min, 6mm below skin, vein diameter 6mm
7. Early fistula thrombosis is associated with Females, Forearm AVF, Small Arterial Size, Small Outflow vein and
Protamine use
a. Diabetes and stiff non-compliant feeding arteries associated with LOWER frequency of early thrombosis
8. Regional anesthesia allows for vasodilation of the vein and artery, leading to increased flow in the fistula. The
increased flow lasts for 8-weeks after the surgery.
9. Diabetes and Female gender associated with higher failure rate of AVF at the wrist
a. Basilic Vein Transposition have higher failure rate in obese people
10. If a fistula has not matured, obtain a duplex for assess for inflow and outflow stenosis
11. If high output cardiac failure from AVF, performed a outflow banding to preserve access and decrease the volume
12. The HeRO graft has become an important option for patients with chronic venous outflow occlusive disease. Its
proximal anastamosis to an artery or existing hemodialysis access and its direct outflow into the right atrium allows
bypass of venous occlusion while maintain hemodialysis access without the need for a bridging tunneled dialysis
catheter.
13. Early cannulation of AVG can be attempted in some patients to avoid dialysis catheters (catheters should be avoided
in immunocompromised patients and those who have had previous catheter infections).
a. Early cannulation can be done within 24 hours of the implantation
14. For HDC’s, if history HIT  Lock with NORMAL SALINE
15. Proximalization of inflow decreases the risk of steal.
16. Buttonhole Stick (Same site), Rope-Ladder Stick (Moving stick site up the fistula)
a. Button hole has increased bacteremia and abscess risk
b. Button hole has decrease hematoma risk
17. Features of access dysfunction include absent thrill, discontinuous bruit, edema, difficulty cannulation, decreased
target blood flow, and prolonged bleeding
a. In the most common surveillance technique, flow measurements are performed with ultrasound dilution,
which determine access blood flow after injecting saline through the reversed-line dialysis circuit. An
ultrasound sensor measures the appearance of saline after injection, and the access flow rate is calculated
with a computer algorithm. Confirmed access flows less than 600 mL/min or greater than 25% below
baseline increase the likelihood for venous stenosis.
b. Patient with issues should have fistulagram for surveillance
18. Patients with HDC are risk for SA bacteremia
a. 1. All patients with S aureus bacteremia with should be evaluated with trans-thoracic echocardiography. 2.
High-risk patients, including all dialysis patients, also should be assessed with transesophageal
echocardiography because of the high rate of endocarditis. 3. Vancomycin and daptomycin are first-line
antibiotic choices for methicillin-resistant S aureus bacteremia, but not for methicillin-sensitive S aureus. 4.
A 14-day course of antibiotics, starting from the day of the first negative set of blood cultures, is only
appropriate for patients with uncomplicated S aureus bacteremia. In patients with S aureus bacteremia, the
Infectious Diseases Society of America recommends placement of a new tunneled catheter once repeat
blood cultures show no growth. In the setting of ESKD, a temporary dialysis catheter may be required to
provide dialysis before the cultures are sterile. Ideally, placement of a tunneled central venous dialysis
catheter should be delayed until repeat blood cultures are negative for 72 hours.
19. Median Antecubital connects drain the cephalic into the basilic at the Antecubital fossa
20. Duplex monitoring of accesses leads to improved stenosis detection with increased fistulagrams. There is inconclusive
data for whether it improves patency.
21. Although AVFs have lower maturation, AVGs thrombose frequently and the graft material is expensive
a. AVF most economical followed by HDC, followed by AVG
22. Compared to an AVG, an AVF tends to mature more slowly, require more procedures to become functional, and lead
to slower removal of a TDC. Once an AVF is established, however, it tends to have better patency and function than
an AVG. In patients already on dialysis through a catheter, there is a large survival benefit from an AVF or an AVG
compared to remaining with TDC
23. Brachial plexus block, gives dilation that results leads to the possibility of using targets that are more distal. Improved
analgesia is also frequently reported. However, the benefit of motor and sensory blockade which lasts 6-12 hours can
also be a disadvantage, because the diagnosis of immediate ischemic steal or ischemic monomelic neuropathy can be
delayed. This could be particularly worrisome if the patient were discharged with the block still in place.
a. Brachial plexus block demonstrated immediate patient satisfaction, and also improved 3-month primary
patency and function for AV fistulas (NOT for AVGs however)
24. Immediate use grafts that have an indication for early cannulation (greater than 72 hours) after implantation. There
have been studies that have demonstrated early cannulation is indeed possible with these grafts
25. Pseudoaneurysms are defects in the wall of the arteriovenous fistula or graft due to the trauma of repeated puncture
for dialysis. They are more commonly seen in prosthetic than autogenous arteriovenous accesses
26. Principles of hemodialysis access surgery stress the need to start as far distally in the extremity as possible. Distal
forearm access is usually limited by unsuitable veins but may also be limited by circumferential arterial calcification,
which can preclude successful fistula maturation. Alternative access will require more proximal arterial inflow, such as
from the brachial or proximal radial arteries. To accomplish this, a patent forearm cephalic vein can be transposed to
the brachial or proximal radial artery in a loop configuration in the forearm.
27. Thrombosis of AVF which was previously working is most commonly due to venous outflow intimal hyperplasia.
28. The optimal study to establish the diagnosis of arterial steal is digital plethysmography with and without compression
of the fistula. Once the diagnosis and its severity is established, a treatment algorithm can be applied.
29. Most dialysis patients whose access is failing will have one or more sites suitable for autogenous AV fistula placement.
Vessel mapping is critical in the evaluation of failing AV grafts to determine what options are available for the patient.
Placing a fistula and allowing it to mature while the old access is still functioning is superior to allowing it to fail and
placing a central venous catheter emergently and then having to continue with the catheter until access maturation.
30. Short-term use of antiplatelet agents, such as aspirin, sulfinpyrazone, or ticlopidine, in the perioperative period has
been associated with lower rates of early fistula thrombosis.
31. Autogenous access is preferred and should be performed well in advance of the need for hemodialysis. Access as far
distal as possible in the nondominant arm is preferred.
32. Best place for short-term HDC is R IJ with tip in the SVC, just above the atrial-caval junction
33. In a prospective randomized study, physical examination alone (before access construction) was found to be sufficient
in patients with adequately visualized vessels on physical examination
34. Access failure that occurs within 30 days of surgery is defined as early access failure. In the absence of a technical
failure, such as a twisted or stenotic anastomosis, it is most commonly associated with inadequate venous outflow,
which may be secondary to inadequate caliber of the outflow vein or central venous stenosis.
35. Ischemic monomelic neuropathy is a rare complication of vascular access that requires prompt recognition and
treatment to avoid permanent neurologic injury. The complication is seen almost exclusively in diabetic patients and
presents immediately after creation of an arteriovenous access in the brachiocephalic or antecubital position. The
underlying cause is sudden diversion of the blood supply to the nerves of the forearm and hand with resulting injury
to nerve fibers. Untreated patients develop a claw-hand deformity with loss of function and severe neuropathic pain.
Immediate ligation of the access is required to reduce the risk of irreversible neurologic injury.
36. Due to the higher risk of complications associated with short-term catheters, in particular infection, they should be
removed or converted to a long-term catheter after 3 weeks of use. To avoid central venous stenosis, the subclavian
vein approach should be avoided if at all possible.
37. Access failure that occurs within 30 days of surgery is defined as early access failure. In the absence of a technical
failure, such as a twisted or stenotic anastomosis, it is most commonly associated with inadequate venous outflow,
which may be secondary to inadequate caliber of the outflow vein or central venous stenosis.
a. If no signs of venous outflow stenosis (no edema)  likely due to small outflow vein caliber
38. –
39. Brachiocephalic AV: Because of the higher flow volumes, they have a higher risk of steal syndrome and a higher
incidence of cephalic arch stenosis. Ischemic monomelic neuropathy is an uncommon but potentially devastating
condition affecting all three forearm nerves. This occurs uniquely after autogenous and prosthetic accesses based on
the brachial artery.
40. Infection rates are higher with short-term dialysis catheters compared with long-term dialysis catheters since they are
tunneled
41. High-output AVF: Ligation of the fistula has been used to manage this condition, but results in loss of access. Banding
of the fistula has been recommended, using intraoperative measures of fistula flow to assess efficacy. Re-siting the AV
anastomosis to a smaller, distal artery has been used successfully to reduce fistula flow and correct CHF while
maintaining fistula patency, although this is a larger procedure than banding.
42. Perigraft seromas may lead to graft infection, skin necrosis, graft thrombosis, or loss of graft puncture area. Some
perigraft seromas resolve spontaneously but most require intervention. A number of treatments have been proposed,
but removal of the seroma and replacement of the involved portion of graft have the highest cure rate.
43. –
44. Steal is more common in upper arm grafts and less in distal autogenous fistulas. Patients with clinically symptomatic
arterial steal should be evaluated with an arteriogram to identify any proximal arterial stenosis. Treatment of the
proximal artery alone with either endovascular or open surgical techniques may resolve symptoms. In patients
without proximal arterial stenosis or who do not resolve their symptoms with treatment of the inflow stenosis,
further treatment options exist. Ligation of the access will resolve the symptoms, but it leaves the patient without an
access for dialysis. Banding of the access outflow tract increases the resistance in the fistula. However, it may be
difficult to judge the degree of stenosis required to alleviate the steal without causing thrombosis of the access. Distal
revascularization with interval ligation (DRIL) involves ligation of the arterial outflow tract just distal to the arterial
anastomosis, followed by a bypass from the artery proximal to the anastomosis to the artery distal to the area of
ligation. The DRIL procedure is effective in treating ischemic pain and tissue loss, but may be less effective for
neurologic deficits that have already occurred.
45. Organisms most commonly associated with catheter infections are Staphylococcus, Enterococcus, and Pseudomonas.
46. It is necessary to ensure digital flow adequacy from the ulnar artery prior to utilizing the radial artery for inflow.
47. –
48. Upper extremity arterial inflow may be further evaluated with either segmental pressures and pulse volume
recordings (PVRs) or arteriography. If a decision is made to use upper extremity segmental pressures and PVRs, the
left and right upper extremities are compared to each other. Any abnormality on the left compared to the right
should prompt either alternative site selection or arteriography. However, if the right upper extremity is chosen as an
alternative site, this may also have an underlying arterial inflow abnormality, although not as significant as the left,
which may lead to another early access thrombosis. Therefore, arteriography remains the gold standard, allowing the
surgeon to both identify and possibly treat an arterial inflow stenosis.
49. Subclavian vein stenosis may be treated by endovascular or open surgical methods, but due to their minimally
invasive nature, endovascular techniques should be attempted first. Successful central venous angioplasty with high-
pressure balloons can be successful, but with limited durability. Bare metal or covered stents post angioplasty would
seem to increase durability, but this remains to be proven. Currently, application should be reserved for suboptimal
angioplasty results or recurrent stenosis. If endovascular methods are not possible or are unsuccessful, open surgical
methods include subclavian to internal jugular bypass and jugular turndown.
50. If any abnormality is noted on pulse examination, the patient should be further evaluated with either upper extremity
segmental pressures and pulse volume recordings (PVRs) or arteriography.
51. Small PSAs at the puncture site may be monitored without intervention, but dialysis personnel should be instructed to
use alternative sections of the access for cannulation. Intervention is indicated if a PSA appears to be expanding or
becomes ulcerated. Traditional open surgical treatment is to bypass around the involved portion of the AV access and
replace it with either transposed vein or prosthetic graft. An alternative approach is endovascular treatment with
covered stent grafts. However, endograft deployment may lead to a higher incidence of future complications at the
access site, especially in the presence of skin erosion.
52. Stenting should be avoided at the thoracic inlet, since risk of fracture
53. Outflow obstruction is commonly located in the subclavian vein due to intimal hyperplasia associated with central
venous catheters, but it may also be located anywhere along the venous outflow tract. Clinical presentation ranges
from asymptomatic, with only increased dialysis venous pressures, to symptomatic, including prolonged puncture site
bleeding, extremity edema, varicosities, pigmentation, dermatosclerosis, and venous ulceration.
54. If steal, and there are concomitant neurologic symptoms (weakness, loss of sensation)  LIGATE the fistula

AORTIC AND ILIAC ARTERIAL DISEASE:

1. Diabetes is protective for AAA formation


2. Open aortic aneurysm repair has a 3- to 6-fold higher risk of 30-day mortality as compared to EVAR, as shown by the
EVAR-1, DREAM trial, and OVER trial. The early survival benefit after EVAR, however, persists for approximately 2 to 3
years, after which time the estimated survival becomes similar to open repair.
a. Compared to open repair, EVAR has higher risk of later rupture
3. Persistent type II endoleaks are associated with hypogastric coil embolization, distal graft extension, the absence of
chronic obstructive pulmonary disease, age 80 years and older, and graft type
4. Renal transplant recipients have significantly improved survival with modern immunosuppression, resulting in more
people requiring aortic aneurysm repair with a solitary transplant kidney.
a. Both endovascular and open aneurysm repairs have been described for repair of aneurysms in renal
transplant patients. Kidneys can tolerate a warm ischemia time of approximately 50 minutes, although a
warm ischemia time less than 30 minutes is highly desirable.
b. Techniques of renal protection during open repair include temporary shunts/bypasses [aorta-iliac,
aortofemoral, subclavian or axillofemoral], in situ renal perfusion with a pump oxygenator by way of
cannulation of the femoral vessels, and explantation with temporary perfusion of the kidney followed by
reimplantation. Intraoperative renal protection during endovascular aneurysm repair (EVAR) can be
achieved by minimizing intravenous contrast and maintaining adequate hydration.
c. Ipsilateral iliac artery sheath, wire, and catheter access should be minimized to prevent transplant
embolization or iliac artery occlusion.

5.
a. 1B endoleak  Treat by extending the right limb in to the distal common iliac or external iliac artery
6. Highest risk for ischemic colitis after AAA repair is with open surgery for ruptured AAA
7. Middle aortic syndrome (MAS), results from a narrowing of the abdominal or distal descending thoracic aorta. MAS
may be congenital or acquired, caused by Takayasu’s or temporal arteritis or by a variety of other inflammatory
causes. Segmental aortic stenosis may be located at the suprarenal, inter-renal, or infrarenal aorta, with a high
propensity for concomitant stenosis in both the renal and visceral arteries.
a. Of note, most patients with middle aortic syndrome present in childhood or the teen years with
claudication symptoms or severe hypertension.
8. SVS grade II BTAI has been shown to correlate with the risk of aortic rupture and aortic-related mortality.
a. According to current SVS guidelines, TEVAR is the recommended treatment for patients with amenable
anatomy when repair of grade II injury is required. Blood pressure control is advocated for all patients
leading up to repair or during nonoperative management approaches. Current SVS guidelines suggest that
this injury should undergo urgent TEVAR for repair within the first 24 hours.

b.
9. The need for left subclavian artery (LSA) coverage in the setting of TEVAR for BTAI is not an uncommon occurrence
a. The vast majority of trauma victims requiring TEVAR tolerate LSA coverage without adverse events, but they
do require monitoring for the development of ischemic arm symptoms or subclavian steal in the
postoperative setting.
10. According to the Aortic Trauma Foundation retrospective multicenter BTAI study, CT angiography is currently used for
the diagnosis in the majority of instances of BTAI.
11. Grade-3 is the most common BTAI
12. The most frequent complications following TEVAR for BTAI were endograft malposition and endoleak
13. A Mattox maneuver (left-sided medial visceral rotation) provides improved exposure to the suprarenal aorta, while a
Cattel-Braasch maneuver (right-sided medial visceral rotation is optimal for exposure of the inferior vena cava and the
origins of the renal veins.
14. A variety of revascularization tools can be utilized in the treatment of acute aortic occlusion. These include
transfemoral embolectomy, transperitoneal aortoiliac thrombectomy, axillobifemoral bypass, aortofemoral bypass
and endovascular therapy (including thrombolysis and angioplasty with or without stenting). The selection of the
appropriate therapy requires careful consideration of the particular clinical scenario and patient risk factors.
a. Delay in diagnosis is common, with spinal cord pathologies being the most commonly pursued alternative
diagnosis.
15. Abdominal compartment syndrome is much more common after rupture aneurysm repair. Risk is not related to open
versus endovascular repair
a. The risk is higher for patients with hemodynamic instability and need for more blood transfusion
b. Free intraperitoneal rupture tends to be associated with increased instability as in this image.
c. Immediate decompressive laproatomy would be the desired treatment rather than aggressive fluid
resuscitation.
16. Post aneurysm repair colon ischemia: If stable continued observation with hemodynamic support is the most
reasonable choice. If patient is hemodynamically unstable due to sepsis or full thickness ischemia is suspected,
laparotomy would be recommended to evaluate and possible partial colon resection
17. -
18. Multiple case series and prospective cohort studies have shown the benefit of EVAR in decreasing the risk of renal
failure and also mortality benefit.
a. The risk of abdominal compartment syndrome is similar between EVAR and open surgical groups and spinal
ischemia is uncommon after repair of AAA.
19. Air may be present for a matter of days to weeks after an EVAR, but should not persist for months or years. This
finding is pathognomonic for a graft infection. Chronic infection in other anatomic sites, groin complications after
EVAR, and rupture are risk factors for endograft infection. Treatment is graft excision with in situ or extra-anatomic
reconstruction. In situ reconstruction may be performed with Rifampin-soaked Dacron, femoral vein, or aortic
homograft. The risk of mortality for this operation is higher than those explants performed for endoleak.
20. Acute EVAR limb occlusion: This is most common in the first 6 months after repair and is more common with the
older generation endografts.
21. –
22. Aortoenteric Fistula: Endovascular repair can be used as a temporizing bridge therapy in some patients in extremis,
but is not a definitive therapy. Surgical repair should be done when the patient is HDS.
23. Type B dissections, which are confined to the descending thoracic aorta, are initially treated medically in the absence
of complications. Complications include malperfusion syndromes (spinal, intestinal, renal, or lower extremity
ischemia) or rupture. The goal of medical therapy is to decrease blood pressure and dP/dT, thereby avoiding rupture
and arresting the propagation of the dissection. The mainstay of care is the administration of an intravenous beta-
blocker titrated to achieve a heart rate of 60 to 80 and systolic blood pressure of 100 to 120 mm Hg. The
administration of a direct vasodilator, such as sodium nitroprusside, should be avoided as initial therapy. Although
effective in lowering blood pressure, these agents can stimulate a catecholamine response, thus increasing dP/dT.
Surgical therapy is reserved for complications, such as rupture or malperfusion of renal, mesenteric, or lower
extremity vessels.
24. TEVAR can be lifesaving in patients with complications from acute type B aortic dissection (TBAD). The role of TEVAR
in patients with uncomplicated TBAD is unclear. Although there is significant controversy, most experts still
recommend medical management with periodic surveillance since there is a lack of convincing evidence to show a
benefit for TEVAR in these patients.

25. Acute type B aortic dissections are initially managed medically. Surgical or interventional treatment is reserved for the
development of complications such as malperfusion and rupture. Malperfusion chiefly causes ischemia involving the
visceral vessels or iliac arteries. Reactive pleural effusions are common after an acute dissection and are not in and of
themselves an indication for surgical repair. Dissections frequently extend into the orifices of the renal and
mesenteric vessels. As long as there are no signs of end organ ischemia, medical treatment is preferred. Complete
thrombosis of the false lumen is a favorable prognostic sign so would not be an indication for repair. TEVAR is best
avoided in patients with connective tissue disease such as Marfan’s syndrome.
26. Acute type A dissections are with rare exceptions treated surgically with urgent ascending aortic graft replacement.
Without surgery, these dissections are associated with a high rate of fatal complications from cardiac tamponade,
acute aortic valvular insufficiency, or dissection into the coronary arteries. Uncomplicated acute type B dissections
are initially treated medically. Open surgical aortic graft replacement historically carries a high risk of mortality and
spinal cord ischemia.
27. Retrograde type A aortic dissection is one of the most serious complications when performing TEVAR for acute type B
aortic dissection.
28. Currently, the standard of care for uncomplicated type B aortic dissection is medical therapy focused on lowering
systolic blood pressure and heart rate.
a. Aneurysmal degeneration is the most common long-term complication responsible for almost all of the
procedures performed after 90 days. Other indications for repair include renal, mesenteric or lower
extremity ischemia, retrograde type A dissection, or intractable pain.
29. Penetrating aortic ulcer (PAU) with surrounding intramural hematoma (IMH). PAU and IMH are two aortic entities
that are closely related. PAUs often occur in patients with extensive atherosclerosis and is characterized by disruption
of the aortic media. IMH is a collection of thrombosed blood in the media, which is essentially a dissection without an
entry tear and with a thrombosed false lumen. There is considerable overlap between the two conditions and some
consider them to be different manifestations of the same condition. Upwards of 80% of PAUs will have an associated
IMH. These lesions can occur anywhere along the aorta, including the ascending aorta. These lesions differ from
classic dissection in that they rarely propagate into branch vessels, they rupture more frequently, and they are
generally more common in older patients because they are associated with a large atherosclerotic burden. Because
PAUs are usually associated with IMH, the placement of a stent graft may be problematic if the graft lands in friable or
dissected tissue. For this reason, some surgeons prefer open repair. Others argue that the older patient population is
better served by TEVAR but recommend relatively long graft coverage to ensure exclusion of potentially disease
segments. TEVAR has been shown to be both safe and effective in managing PAU and IMH.
30. Paraplegia resulting from spinal cord ischemia (SCI) is perhaps the most feared complication after thoracic aortic
surgery.
a. The mechanism of SCI is postulated to occur from the triad of disruption to the spinal cord’s collateral
arterial network, decreased spinal cord perfusion pressure, and ischemia/reperfusion to the cord. Adjuncts
to limit the effect of each have been used to decrease the incidence of SCI. Spinal cord perfusion pressure is
equal to the arterial perfusion pressure minus the cerebrospinal fluid (CSF) pressure. A high aortic cross
clamp causes proximal hypertension with an increase in CSF pressure, thereby decreasing spinal cord
perfusion. Perfusion pressure can be maintained by both decreasing CSF pressure with a lumbar or spinal
drain and permitting relative arterial hypertension. There is considerable evidence that CSF drainage
improves blood flow to the spinal cord. It has been shown that SCI can develop as late as 2 weeks after
repair and placement of a spinal drain is effective in reducing symptoms.
31. Emergent conversion from an endovascular to an open procedure is uncommon, but associated with significant
increase in both morbidity and mortality. Factors that predict the need for acute conversion include increased
aneurysm diameter, young age, female gender, and nonwhite race.
32. The transperitoneal approach with left medial visceral rotation and mobilization of the spleen and pancreas to the
right allows for good exposure of the paravisceral aorta extending up to the level of the diaphragm, while still
allowing access to the mid-SMA
a. Exposure of the distal SMA for bypass or to ensure a reasonable endpoint after endarterectomy is difficult
from a retroperitoneal approach.
33. Any form of infrarenal endovascular repair is at significant risk for further aneurysmal degeneration of her proximal
neck and development of a type IA endoleak. Bilateral renal artery snorkels would allow additional seal zone in the
pararenal segment and allow use of off-the-shelf components in an urgent or emergent situation. However, it likely
would perform less well over time than renal fenestrations, because of issues with gutter endoleaks and renal
mobility with breathing.
34. -
35. Multiple adjunctive measures are currently used to decrease paraplegia risk after both open and endovascular
thoracoabdominal repair. The increase risk appears to correlate with segmental arteries sacrificed. In general,
patients undergoing extent II thoracoabdominal aneurysm repair have the highest risk of paraplegia. Diabetes is
associated with increased paraplegia risk. Lumbar drainage, distal perfusion (using left heart bypass, cardiopulmonary
bypass or circulatory arrest), and spinal cord hypothermia have all been demonstrated to significantly decrease
paraplegia risk. Delayed paraplegia may be secondary to a “second hit” phenomenon where a vulnerable patient
develops postoperative hypotension, lumbar drain malfunction, or bleeding. In any event, delayed paraplegia has a
better prognosis than immediate paraplegia
a. Some delayed patients recover neurologic function by discharge with the use of adjunctive measures such
as elevation of mean arterial pressure and lumbar drainage. Immediate paraplegia may be secondary to
diffuse embolization to the spinal cord, which is less recoverable by methods used to enhance spinal cord
perfusion pressure.
36. The variable size and anatomy of renal arteries need to be taken into consideration when assessing patients for
possible fenestrated endovascular repair, especially when the patient is a reasonable candidate for open repair. Renal
arteries smaller than 5 mm have increased risk for stenosis after covered stent placement.
a. Unstented fenestrations are more likely to lead to renal occlusion because of the dynamic movement of the
fenestrated main body, the renal arteries, and the aorta. Early bifurcation of the renal artery usually
requires sacrifice of one of the branches by the covered stent. Although multiple accessory renal arteries
can be accommodated with large fenestrations or covered if small, the patient may or may not have a
dominant renal artery of appropriate size to allow for a stented fenestration.
37. Renal insufficiency and especially preoperative hemodialysis is predictive of significantly worse outcomes for multiple
vascular procedures. This is perhaps most marked for open thoracoabdominal aneurysm repair, given the maximal
invasiveness and significant cardiopulmonary stressors associated with this procedure.
38. –
39. Left subclavian revascularization is recommended, if the subclavian artery origin will be covered, but not mandatory
acutely.1 Immediate repair is recommended for Grade 3 and Grade 4 injuries, whereas Grade 1 and some low-risk
Grade 2 injuries may be safely managed with observation
a. Grade 1 – intimal tear; Grade 2 – intramural hematoma; Grade 3 – pseudoaneurysm; Grade 4 – rupture.
40. Zone 2 coverage is defined by coverage of the left subclavian artery, but distal to the left common carotid artery.
a. The phrenic nerve courses anterior to the anterior scalene muscle in normal anatomy, but can pass through
the body of the scalene muscle in a small number of cases.
41. The left common iliac vein courses posterior to the right common iliac artery to join the right common iliac vein.
Penetrating injuries to this area of the left common iliac vein may require division of the right common iliac artery to
facilitate exposure of the iliac venous confluence and repair complex venous injuries. This anatomic relationship of
the left common iliac vein to the right common iliac artery is important in the etiology of left common iliac vein
thrombosis (May-Thurner syndrome)
42. Surgical control of the retroperitoneal bleeding is difficult. If the self-tamponade is released by opening the pelvic
retroperitoneal space, uncontrollable bleeding from numerous vessels and raw fracture surfaces may result.
Angiographic embolization provides a better alternative to surgery in managing retroperitoneal bleeding. In most
cases, bleeding branches of the internal iliac artery are identified and embolized directly. The use of a temporary
material (gelatin sponge) to occlude the vessel theoretically ensures patency at a later stage. Gelatin sponge dissolves
within 2 to 10 days, and blood flow is reconstituted. Coil embolization can also be performed, however, it may have
more permanent complications. Less common complications of arterial embolization include ischemic necrosis of
rectum, muscles, and peripheral nerves, and paralysis or paresthesia. Delayed skin and muscle necrosis of the gluteal
region following internal iliac artery embolization may lead to uncontrollable gluteal infection.
43. Direct laceration of the iliac vessels from a pelvic fracture or stretching of the iliac artery over the pelvic wall, resulting
in intimal tear and subsequent thrombosis, is the usual mechanism of injury after blunt trauma. Blunt injuries to the
common iliac artery and the external iliac artery are associated with significant morbidity and mortality. Patients are
at high risk for early death and proximal leg amputation, requiring rapid diagnosis and treatment. These injuries
frequently present with lower extremity malperfusion and pelvic soft-tissue trauma, which are risk factors for
amputation. Endovascular techniques may play an important role in selected cases of iliac artery injury, especially
after blunt trauma. Patients with pseudo-aneurysms, arteriovenous fistula, or major intimal tears with or without
thrombosis may benefit from angiographically placed endovascular stents. Because of its safety and low complication
rate, this should be the first-line therapeutic option in elective cases in patients with subacute or chronic traumatic
lesions of the common or external iliac arteries.
44. A partial injury to the left common iliac vein can be very difficult to control and can be a source of continued
hemorrhage. The most efficient way to handle this injury is by clamping and dividing the overlying right common iliac
artery and repairing or ligating the iliac vein.
45. -
46. Infected EVAR: in situ repair with any of several aortic conduits, including rifampin-soaked Dacron, femoral-popliteal
vein, and cryo-preserved homograft. Each of these conduits has merit and none is ideal for every case. Endograft
infections pose a particular challenge because many grafts have supra-renal fixation that can be challenging to
explant and the juxta-renal aorta is often damaged by graft excision. In these cases, aortic ligation can be even more
challenging, so most surgeons with experience with this clinical problem have resorted to in situ repair since this
approach is technically feasible by suturing to the aorta at the level of the renal arteries. Of note, there are technical
“tips” for removal of the grafts, including the use of supra-celiac or supra-renal aortic control and techniques for
removal of supra-renal barbs, that should be reviewed prior to undertaking explantation of an infected aortic
endograft.
47. Intracavitary graft infections can be extremely challenging to manage. They carry a high rate of mortality, limb loss,
and re-infection. The previous standard for the treatment of graft infections was: (1) complete graft explant, (2)
arterial ligation, and (3) extra-anatomic bypass. More recent data suggest that in situ reconstruction with rifampin-
soaked dacron grafts, allografts, or neoartoiliac reconstructions using deep vein offer superior results and avoid some
of the limitations of aortic ligation and extra-anatomic bypass. In situ reconstructions are expedient, avoid an aortic
stump, and may be associated with lower amputation rates. In addition, and depending on the length of the aortic
neck between the renal arteries and proximal graft, they avoid renal artery reconstructions to achieve aortic closure.
Low-virulence infections (e.g., Staphylococcus aureus or Staphylococcus epidermis) have favorable outcomes with in
situ reconstructions, whereas polymicrobial infections (gram-negative rods, anaerobes, and fungi) are associated with
higher mortality and re-infection rates.
a. If gross infection, purulence, and tissue necrosis identified in the operative theater is indicative of the
autolytic enzymes produced by polymicrobial infections, in-situ should be avoided and extra-anatomic
should be considered
48. –
49. Abdominal compartment syndrome (ACS). Four factors for the development of ACS following EVAR for ruptured
abdominal aortic aneurysms: use of an aortic occlusion balloon, massive transfusion, coagulopathy, and need to
convert to an aorto-uniiliac device. In addition, shock, cardiac arrest, and initial hemoglobin less than 10 mg/dl have
been associated with ACS
50. Despite multiple avenues of research into aortic pathology, medical management to limit aneurysm growth is largely
ineffective
51. Aortocaval arteriovenous fistula: It arises as a result of contained aneurysm rupture into the vena cava. No attempts
should be made to mobilize the vena cava or other structures. Rather, the hole in the aortic wall should be fixed
primarily from within the aneurysm.

Renal and Mesenteric Vascular Disease

1. Acute mesenteric ischemia (AMI) is a surgical emergency. The underlying causes include embolic or thrombotic
occlusion, nonocclusive mesenteric ischemia and mesenteric venous thrombosis. Arterial embolism is the most
common pathophysiologic mechanism of AMI and accounts for nearly 50% of cases. Most emboli arise from a cardiac
source.
a. Hypercoagulable states and acute pancreatitis are the two most common conditions associated with SMV
thrombosis
b. In patients presenting with a known history of atrial fibrillation who are not anticoagulated, the first
thought should be of a thromboembolic event. In the absence of other significant comorbidities, underlying
chronic arterial disease is much less likely. Full small bowel necrosis suggests an embolic occlusion of the
superior mesenteric artery just distal to the middle colic branch. With a celiac artery occlusion, less small
bowel would be affected. The diagnosis of nonocclusive mesenteric ischemia is made in the setting of a low-
flow state, such as a severe bout of heart failure requiring inotropic support. Mesenteric venous thrombosis
typically develops secondary to a hypercoagulable state or some prior surgical interventions, such as
splenectomy.
2. Computed tomography is the most important and accurate tool in the diagnosis of mesenteric venous thrombosis
(MVT). In most cases, MVT is not suspected, with the diagnosis made by the radiologist based on findings on a CT scan
performed for abdominal pain of unknown etiology. Optimal imaging can be performed using a three-phase scanning
protocol, in which the delayed portal venous phase can accurately identify MVT.
3. Segmental arterial mediolysis (SAM) is a rare, acute, often self-limiting disorder generally limited to visceral vessels.
The diagnosis remains clinical and aided mainly by imaging from CT and conventional angiography. The mean age at
presentation is usually 60 years with no clear gender prevalence and no familial or genetic predisposition. Intra-
abdominal arteries are most commonly involved, including the mesenteric, gastric, splenic, and pancreatic arteries.
The arterial injury is thought to originate at the adventitial-medial border. Overstimulation of alpha-1 receptors may
lead to intense vasoconstriction followed by apoptosis or shearing separation of the adventitia from the media,
resulting in bleeding at the adventitial-medial junction. The classic arterial findings of SAM include arterial dilatations,
aneurysms, hematomas, stenosis, and occlusions .
a. Can mimic PAN and FMD
4. Compression of the distal segment of the left renal vein between the superior mesenteric artery (SMA) and the aorta
is referred to as the nutcracker phenomenon. The symptoms associated with venous stasis in the left kidney are
called the nutcracker syndrome. The main symptoms are left flank pain radiating to the buttock and hematuria (from
microscopic to gross). Compression of the distal part of the left renal vein is generally due to the SMA arising from the
aorta at an acute angle, causing a “scissoring effect” on the left renal vein. Compression may be aggravated by the
standing position. Compression can also occur in patients with a retroaortic left renal vein wherein the aorta
compresses the vein against the spine. The right kidney is not involved in the nutcracker system. The gonadal vein
serves as an important collateral in the venous drainage of the left kidney when the renal vein is compressed.
5. Catheter-based angiography remains the most accurate imaging technique to diagnose and evaluate fibromuscular
dysplasia (FMD).
6. Duplex criteria consistent with significant stenosis of the mesenteric arteries include a peak systolic velocity greater
than 275cm/sec for the superior mesenteric artery and a peak systolic velocity greater than 200 cm/sec for the celiac
artery, representing a stenosis of 70% or greater.
7. Most hepatic artery aneurysms are extrahepatic
a. Common > Right Hepatic > Left Hepatic
8. In theory, a unilateral stenosis should rarely cause significant renal function since a normal contralateral kidney
should provide adequate glomerular filtration. For that reason, treating bilateral moderate to severe stenoses with
renal artery stenting is more likely to be associated with improvement in renal function, compared to treating a
higher grade unilateral stenosis.
9. Selective embolization is currently the preferred treatment for renal arteriovenous malformation.
10. Splenic artery aneurysms are the most common visceral artery aneurysms, occurring with a female to male ratio of
4:1. Rupture is rare when aneurysms are smaller than 2 cm in diameter. During pregnancy, however, rupture leads to
mortality approaching 70% mortality for the mother and 75% for the fetus. For that reason, the single most
compelling indication for is planned pregnancy. Treatment is often recommended when the diameter exceeds 2 cm,
even though the data underlying that recommendation are poor. Treatment may consist of coil embolization, stent
grafting, or splenectomy.
11. Synthetic bypass grafts of 6- to 8-mm Dacron or externally supported polytetrafluoroethylene (PTFE) are preferred
because of the better size match, ease of handling, availability, kink resistance, and general perception that long-term
patency is better. The superior patency of prosthetic mesenteric bypasses, however, is not well documented.
Therefore, the choice of conduit is heavily influenced by the degree of abdominal contamination and the risk of
subsequent graft infection. The actual rate of graft infection is not known with certainty, but when present, it is
potentially catastrophic and likely to involve virulent organisms. Therefore, if good-quality vein is available, it is
preferred in the presence of significant peritoneal soilage. If there is overt bowel perforation with soilage, then the
preferred treatment for this patient would be the use of saphenous vein. However, overt necrotic bowel should be
resected immediately to avoid further soilage of the peritoneal cavity.
12. Current indications for surgery in patients with acute MVT include signs of peritonitis, bowel infarction, and
hemodynamic instability. Reducing the need for high doses of the lytic agent, local thrombolysis via a transhepatic or
transjugular route also allows for balloon venoplasty and stenting for post-thrombotic stenotic lesions, when needed.
Endovascular if no evidence of frank bowel infarction and the patient is having worse pain despite being
anticoagulated.
a. Initial treatment of mesenteric venous thrombosis is anticoagulation with systemic heparin. In a patient
with a worsening clinical examination and bowel ischemia, exploratory laparotomy should be the next
modality undertaken.
13. The natural history of a pancreatic pseudoaneurysm of the splenic artery differs from that of a splenic artery
aneurysm due to atherosclerosis. The natural history is poorly defined with bleeding a potential consequence. For
that reason, treatment is often undertaken, with covered stent placement a reasonable option.
a. Distal pancreatectomy and urgent splenectomy would be considered if hemodynamically unstable.
14.
a. When the midline xiphoid to pubis incision is used, the posterior peritoneum overlying the aorta is incised
longitudinally and the duodenum is mobilized at the ligament of Treitz. During this maneuver, it is
important to identify and to spare the meandering mesenteric vessel that courses at this level. The
duodenum is reflected to the patient's right to expose the left renal vein. By extending the posterior
peritoneal incision to the left along the inferior border of the pancreas, an avascular plane posterior to the
pancreas can be entered to expose the entire left renal hilum. This exposure is of special importance when
there are distal renal artery lesions to be managed. The left renal artery lies posterior to the left renal vein.
The vein can be retracted cephalad to expose the artery; in other cases, caudal retraction of the vein
provides better access. Usually, the gonadal and adrenal veins, which enter the left renal vein, must be
ligated and divided to facilitate exposure of the distal artery. Frequently, a lumbar vein enters the posterior
wall of the left renal vein. It can be injured easily unless special care is taken.
15. Renal Artery Aneurysms:
a. Although arteriosclerotic changes have been identified in most aneurysms in patients with multiple lesions,
this is not a uniform finding, suggesting that arteriosclerosis may not be the most important factor in the
genesis of renal artery aneurysms. These aneurysms are more likely due to a congenital medial
degenerative process with weakness of the elastic lamina. The majority of renal artery aneurysms are
saccular. Fibromuscular dysplasia (FMD) is often a direct contributor to the development of an aneurysm.
Medial fibroplasia is typically associated with multiple stenoses and post-stenotic dilatation of the distal two
thirds of the renal artery. Renal artery aneurysms in association with FMD are generally only a few
millimeters in diameter. The typical angiographic appearance of a renal artery involved with medial
fibroplasia is a “string of beads.”
16. There are many important collateral pathways in the mesenteric circulation. The meandering artery is usually the
most prominent. It connects the superior mesenteric and inferior mesenteric arteries via the middle branch of the
middle colic artery and the ascending branch of the left colic artery. These connections can allow for perfusion of the
superior mesenteric territory, as in this patient. The pancreaticoduodenal arteries connect the celiac axis and the
superior mesenteric artery. The marginal artery of Drummond also provides collaterals between the superior and
inferior mesenteric arteries. Hypogastric collateral pathways typically arise from the hemorrhoidal artery.
17. Pancreaticoduodenal artery aneurysms account for roughly 10% of splanchnic aneurysms. These lesions (along with
aneurysms of the gastroduodenal artery) have a higher propensity to rupture than other splanchnic lesions, and
should typically be addressed, regardless of the presence of symptoms. They can usually be repaired in contemporary
series via endovascular techniques.
18. The inferior vena cava can often be repaired via lateral venorrhaphy, and in penetrating trauma, synthetic patches
should generally be avoided. Infrarenal inferior vena injuries are usually approached via medial rotation of the right
colon, hepatic flexure, and duodenum. This is a Cattell-Braasch maneuver.
19. Although complications following renal artery interventions are uncommon, they can occur and must be appreciated.
The most common of these are access site issues, including femoral pseudoaneurysm.
20. The median arcuate ligament is the portion of the diaphragmatic crura that is anterior to the aorta and superior to
the celiac axis. Median arcuate ligament syndrome is characterized by bloating, nausea, and vomiting and often
entails a lengthy work up. Compression of the celiac axis is often demonstrated on imaging modalities in
asymptomatic patients. In MALS, gastric ischemia is often not identified. Compression demonstrated during full
expiration on arteriography along with appropriate clinical symptoms would be consistent with MALS.
a. Laparoscopic decompression of the celiac axis is effective and stenting is reserved for patients with
continued symptoms. Median arcuate ligament syndrome involves only the celiac axis, and the superior
mesenteric artery is rarely involved.
21. If acute mesenteric ischemia is suspected, in confirming the diagnosis, a lactate value within normal limits should not
be reassuring, as it could be early in the course of the disease process.
a. Computed tomography arteriography is the preferred method for making the diagnosis. It can identify the
location of the superior mesenteric artery occlusion as well as evaluate the bowel for signs of ischemia.
22. Mesenteric venous thrombosis is thrombosis of the superior mesenteric vein with possible extension into the portal
and splenic vein. An etiology is often not found, but it is associated with hypercoagulable states. Initial treatment of
mesenteric venous thrombosis is anticoagulation with systemic heparin. In a patient with a worsening clinical
examination and bowel ischemia, exploratory laparotomy should be the next modality undertaken. Segmental
resection should be performed if necrotic bowel is encountered at the time of exploration. Anticoagulation is
continued and delayed anastomosis is performed.
23. Most SMA aneurysms are located proximally on the SMA. The threshold for repair is usually 2 cm in asymptomatic
patients.
24. The majority of renal artery aneurysms are asymptomatic, and less than 3% rupture.
a. In an elderly patient, observation of this aneurysm with Duplex surveillance is the appropriate treatment.
b. Factors such as calcification are thought to provide a protective factor against rupture.
c. For larger aneurysms in younger patients, aneurysmorrhaphy with primary repair or patching can be
performed
d. Covered stent placement may be difficult in the distal renal artery near potential branch points of the artery
25. Superior mesenteric artery syndrome is characterized by compression of the third portion of the duodenum by the
superior mesenteric artery, which can lead to intermittent or partial duodenal obstruction. The etiology can be a loss
of mesenteric fat from rapid weight loss or catabolic states. The normal aortomesenteric angle is 45 degrees and an
angle less than 25 degrees can be associated with compression of the duodenum.
a. Treat via a nasojejunal tube can restore the nutritional status of the patient and potentially relieve
symptoms.
b. When non-operative management fails, a duodenojejunostomy can be performed to bypass the
obstruction.
26. Antegrade bypass to the mesenteric arteries from the supraceliac aorta is preferred because the graft has a greater
long-term patency and a more straightforward geometry. However, retrograde bypass is reasonable when an
antegrade bypass or aortomesenteric endarterectomy are not feasible. Specific indications for retrograde bypass
include severe cardiac disease, which increases the risk of clamping the supraceliac aorta; inaccessible supraceliac
aorta, due to previous operations; and a severely calcified or aneurysmal supraceliac aorta. When performing
retrograde bypass, in the absence of an infected field, prosthetic graft is preferred because the risk of graft kinking is
lower than with a vein graft.
27. Numerous inciting factors can result in non-occlusive mesenteric ischemia, including myocardial infarction, septic
shock, prolonged infusion of vasopressors, and excess removal of fluid during hemodialysis. The common pathway is
hypotension and hypoperfusion. Angiogram findings with NOMI include spasm of the mesenteric arcades and
alternating dilation and narrowing. Treatment consists of attempting to remediate the source of hypotension or
hypoperfusion. In rare cases, intra-arterial infusion of a vasodilator into the superior mesenteric artery may be
considered.
28. Typically, renal artery FMD responds to angioplasty alone, and stents are not only unnecessary, but lead to a higher
incidence of restenosis. The outcomes for endovascular therapy of FMD are generally superior to those obtained for
atherosclerosis. A recognized risk of angioplasty, however, is the creation of a local dissection that could require a
stent.
29. The SMA is the most common site of mesenteric emboli, which is due to its relatively large caliber and acute angle of
origin.
a. The typical location for an SMA embolus to lodge is 4-10 cm distal to the SMA origin, distal to the take off of
the middle colic artery where the artery begins to narrow. An embolus in this location will produce a
characteristic pattern of ischemia involving the mid and distal jejunum, ileum, and right colon. The proximal
jejunum is often spared because the embolus lodges distal to several proximal jejunal branches off of the
SMA. The transverse colon is usually spared because the middle colic artery remains patent. The left colon
and rectum are supplied largely by the inferior mesenteric artery, so these portions are also spared. Once
acute mesenteric ischemia is suspected, systemic anticoagulation should be instituted with a goal of
expeditious revascularization.
b. Open surgical management includes exposure of the SMA in the root of the mesentery, inferior to the
pancreas and transverse colon. For an embolectomy, a transverse arteriotomy in the SMA permits rapid
passage of Fogarty embolectomy catheters proximally (and distally if necessary) to extract the embolus and
associated thrombus. The advantage of the transverse arteriotomy is that it can be closed primarily, while a
longitudinal arteriotomy requires a patch closure to minimize narrowing of the SMA.
30. Medial fibroplasia is the most common form of fibromuscular dysplasia. An arteriogram can demostrate the typical
string of beads appearance characteristic of medial fibroplasia, as well as an associated renal artery aneurysm. In
medial fibroplasia, there are alternating areas of medial thinning and irregular thickened fibromuscular ridges
containing collagen. Peri-medial fibroplasia is less common, involves the outer half of the media, and tends to have a
smaller bead pattern angiographically. In contrast, intimal hyperplasia has concentric thickening and with an
arteriographic appearance of a smooth narrowing. Medial hyperplasia also has a consistent hyperplastic pattern
resulting in a smooth angiographic appearance. Adventitial hyperplasia is exceedingly rare and involves concentric
thickening of the adventitial layer.
31. Patients with non-occlusive mesenteric ischemia (NOMI) are usually elderly and critically ill with pre-existing
atherosclerotic disease of the mesenteric vessels. The condition was first described in patients with advanced heart
failure and low cardiac output. Patients with NOMI are typically encountered in the intensive care unit, are critically
ill, and are often on vasopressors. Due to its frequent correlation with multiple organ dysfunction syndrome, NOMI
has higher mortality than thromboembolic disease and is often under-recognized.
a. Angiography is the most reliable diagnostic modality. Several angiographic findings have been described,
including vasospasm of SMA, stensosis alternating with dilatation resulting in the characteristic "string of
sausages" appearance, narrowing and tapering of mesenteric branches, and paucity of intramural vessels.
b. The treatment for NOMI is medical and supportive therapy. It is directed towards correcting the underlying
cause, fluid resuscitation, optimization of cardiac output, correction of the low flow state, and elimination
of vasopressors.
32. Patients presenting with acute mesenteric ischemia pose a significant challenge to accurately diagnose the problem in
a timely fashion. The most common laboratory abnormalities include hemoconcentration, leukocytosis, a high anion
gap, and possibly lactic acidosis with more advanced ischemia.
a. However, the most common laboratory abnormality is leukocytosis. Unfortunately, it is not specific for
mesenteric ischemia.
33. If acute mesenteric ischemia is acute thrombosis with underlying atherosclerotic disease. In these cases, at least two
(and commonly all three) of the mesenteric arteries are involved with atherosclerotic arterial occlusive disease. In
such cases, anticoagulation alone is insufficient treatment. Pharmaco-mechanical thrombolysis and catheter-directed
thrombolysis may be options if combined with stenting of the mesenteric arterial occlusive disease after clearing the
thrombus, but that approach is usually reserved with patients without advanced clinical findings that require a
laparotomy. Embolectomy would not be helpful in a patient with pre-existing mesenteric arterial occlusive disease.
The only reasonable option is a mesenteric bypass. Both antegrade and retrograde approaches have been described;
the approach should be tailored to the circumstances.
34. Acute renal vein thrombosis (RVT), a rare form of venous thromboembolism, is frequently associated with the
nephrotic syndrome and is the most common etiology for renal vein occlusion in adults. The anatomy of the renal
vein is of primary importance in understanding the pathophysiological responses to renal vein thrombosis and the
clinical and diagnostic presentation of patients with this condition. The reaction of the kidney to occlusion of its
primary outflow vein is determined by the balance between the acuteness of the disease, the extent of the
development of collateral outflow veins, involvement of one or both kidneys, and the etiology of the underlying
disease. CT angiography is considered the investigation of choice
a. Initial therapy should include correction of any fluid and electrolyte imbalances, dialysis if indicated,
antihypertensive medication, and systemic anti-coagulation. Systemic anticoagulation is achieved with
intravenous unfractionated heparin unless there is evidence of heparin-induced thrombocytopenia, in
which case a direct thrombin inhibitor, such as one of the hirudin derivatives or argatroban, should be
substituted for heparin. In patients without contraindications, percutaneous catheter-directed
thrombectomy (with or without thrombolysis) for acute RVT is associated with a rapid improvement in renal
function and a low incidence of morbidity. Deteriorating renal function is a compelling indication for this
approach. Surgical thrombectomy is rarely used since renal parenchymal thrombus is not cleared with
surgical thrombectomy and commonly leads to failure of this approach.
b. Regardless of the initial approach, all patients should undergo a workup for hypercoagulable states and
receive warfarin therapy for an undetermined period of time (at least 3 months, and longer if a
hypercoaguable state or underlying cancer is diagnosed).
35. Mycotic superior mesenteric artery aneurysm. A history of antecedent bacteremia such as with bacterial endocarditis
is frequently reported.
a. Aneurysmorrhaphy is not a good option because the infected remnant vessel is at risk for catastrophic
deterioration. A covered stent might be considered, but there is a risk of contamination/infection of the
stent graft. In addition, a stent graft would necessitate coverage of multiple jejunal branches of the SMA.
b. Autogenous in-situ reconstruction is most appealing. It reduces the risk of persistence or recurrence of
infection and allows the surgeon to examine the bowel immediately at the time of vascular reconstruction.
Long-term antibiotics are appropriate regardless of the treatment selected.
36. Takayasu's arteritis is a recognized etiology for renal artery stenosis and other stenotic or occlusive lesions of major
aortic branches. Asymptomatic lesions related to Takayasu's arteritis should not be surgically treated, except in rare
circumstances. In this scenario, the patient is clearly symptomatic with renovascular hypertension and ischemic
nephropathy due to bilateral renal artery stenoses, as well as lower extremity claudication. There is a role for steroids
in the treatment of patients in the active phase of their disease with constitutional symptoms or with significantly
elevated ESR or CRP levels.
a. Open bypass for Takayasu's arteritis offers a low incidence of mortality (less than 2%), particularly in this
young and otherwise healthy patient, and excellent long-term outcomes.
37. Renal arteriovenous fistulae (AVF) are classified as congenital and acquired. Congenital AVF are rare with a low
incidence all renal AVFs. Acquired renal AVFs may occur spontaneously and may be associated with fibromuscular
dysplasia, renal artery aneurysms, renal malignancies (such as renal cell carcinoma), or secondary to trauma, such as a
percutaneous kidney biopsy.
a. The majority of both congenital and acquired AVFs do not cause symptoms and do not require treatment.
This is particularly the case with AVFs discovered early after renal artery biopsy. If a post-biopsy AVF persists
after 1 year, it is not likely to close spontaneously. Treatment, however, should be delayed until the
development of symptoms. Treatment of renal AVMs is generally endovascular. Injection of absolute
alcohol is the most accepted endovascular treatment for small AVFs, while large AVFs can be managed with
coil embolization. Partial or complete nephrectomy may be required for large, symptomatic AVFs not
responsive to endovascular treatment.
38. Isolated spontaneous dissection can occur in any visceral artery, although the SMA seems to be the most common
site. Although atherosclerosis, medial degeneration, trauma, fibromuscular disease, pregnancy, and a host of
arteriopathies have been implicated, the underlying cause remains unknown.
a. Conservative treatment with or without antiplatelet agents or anticoagulation is sufficient for asymptomatic
patients. Symptomatic patients, including patients with rupture, acute mesenteric ischemia, or persistent
pain, merit repair with either endovascular stenting or open surgical repair. Aneurysmal degeneration
(greater than 2.0 cm in diameter) is also an indication for repair. The presence of compression of the true
lumen of the SMA, creating a hemodynamically significant stenosis, is considered an indication for, but the
largest series found that observation with anti-platelet therapy or anticoagulation was adequate if there
were not associated symptoms. Serial CT arteriograms to monitor for aneurysmal degeneration of the
affected vessel is recommended.
39. Endovascular management of visceral occlusive disease has been shown to be effective in the short- and mid-term. It
is particularly helpful in high risk patients with significant co-morbidities in whom open revascularization would be
hazardous.
40. Normal superior mesenteric artery (SMA) Doppler waveforms in the fasting patient show high resistance, with a peak
systolic velocity (PSV) less than 275 cm/sec and without spectral broadening. Following a meal, the waveform
becomes low resistance, with a slightly increased PSV and little to no spectral broadening. In the presence of a
significant SMA stenosis (greater than 70% diameter narrowing) in a fasting patient, there is a delay in the systolic
upstroke, a markedly elevated PSV and significant spectral broadening.
a. Due to the stenosis, there is diastolic flow throughout diastole. End diastolic velocity greater than 55 cm/sec
is also consistent with a SMA stenosis greater than 70%.
41. Decreased renal parenchymal perfusion leads to ischemic nephropathy, which has as its hallmarks: glomerular
atrophy, tubulo-interstitial lesions, and fibrosis. It is now recognized that the severity of histopathologic damage is an
important determinant and predictor of renal functional outcome after revascularization. The classification of chronic
renal disease stresses the importance of proteinuria as a marker of renal disease. Proteinuria increases with declining
renal function and reflects the severity of parenchymal damage. Proteinuria, and a high renal resistive index, are
associated with glomerular damage and altered intrarenal perfusion. Loss of parenchyma leads to renal atrophy. The
risk of renal atrophy is highest in patients who have an elevated systolic blood pressure, high-grade renal artery
atherosclerotic disease, and low renal cortical blood flow velocity, as assessed by renal duplex scanning. Renal
atrophy correlates with changes in the serum creatinine concentration. With progressive renal atrophy, the likelihood
of any retrieval of any meaningful renal function from the atrophied kidney with revascularization declines. Normal
kidney length is 10 to 12 cm, so a 6 cm kidney is quite atrophic and probably irreversibly sclerotic. A renal resistive
index value greater than 0.8 can reliably identify patients in whom intervention will not improve renal function
42. Splenic artery embolization for hematologic diseases, such as ITP, hereditary spherocytosis, or myelofibrosis, has
become a popular adjunct in the surgical management prior to splenectomy (especially laparoscopic splenectomy).
a. Preoperative embolization has been shown to reduce splenic size and decrease blood loss.
43. Cardiac emboli to the superior mesenteric artery (SMA) typically lodge at major branch points in the SMA where the
caliber of the artery diminishes. The most common site is immediately distal to the takeoff of the middle colic artery.
An embolus at this site typically spares the proximal jejunal branches and proximal jejunum and produces ischemia of
the mid and distal jejunum and ileum. This is in contrast to a thrombotic occlusion of the SMA, which produces
intestinal ischemia involving the small intestine from the ligament of Treitz to the ascending colon. With thrombotic
occlusion of the SMA, the transverse and descending colon are often less ischemic or spared altogether due to
collaterals from the inferior mesenteric artery to these segments of colon. Visualization of a meandering artery is also
an indication of longstanding mesenteric occlusive disease that would point toward thrombotic mesenteric ischemia.
44. The anatomy of the superior mesenteric artery (SMA) and its relationship to surrounding structures is vital to
exposing the SMA for the open surgical treatment of both acute and chronic mesenteric ischemia. To perform SMA
embolectomy, most surgeons expose the SMA in the root of the small bowel mesentery inferior to transverse
mesocolon. Infra-mesocolic exposure of the SMA requires cephalad displacement of the transverse colon. For most
open exposures of the SMA from an anterior, trans-abdominal approach (i.e., not via a left flank or retroperitoneal
approach), the artery is exposed near the root of the mesentery at a location inferior to the pancreas and distal to the
point at which the SMA crosses over the duodenum. At this location, the SMA can be palpated in the mesentery in
most cases, even if it is pulseless. A longitudinal incision in the anterior leaflet of the mesentery in this location will
allow exposure of the SMA in the vicinity of the middle colic artery branch. If the superior mesenteric vein is
encountered, dissection should proceed to the patient's left to identify the proximal superior mesenteric artery. Many
surgeons find it helpful to mobilize the 4th portion of the duodenum to allow the root of the mesentery to be grasped
between the palm of the hand (posterior to the root of the mesentery) and the thumb (rolling over the SMA
anteriorly).
45. A failed retrograde bypass from the infrarenal aorta to the superior mesenteric artery (SMA) can usually be
remediated with the traditional antegrade bypass from the supraceliac aorta to both the celiac axis and the SMA. This
usually requires siting the SMA anastomosis distal to the original one and obviates the concern about the course of
the retrograde graft that may have contributed to the initial failure. A failed antegrade bypass can usually be redone
or converted to a retrograde bypass.
46. Arteriography is essential for both diagnosis and operative planning. Mesenteric arterial disease represents "aortic
spillover disease," which explains the frequency of disease at the origins of the celiac and superior mesenteric
arteries. Because of this, selective catheterization of the mesenteric vessel is rarely needed to make the diagnosis.
Angiographic evidence of disease within the distal vasculature generally suggests a nonatherosclerotic disease
process such as nonocclusive mesenteric ischemia or cocaine/ergot ingestion. Given the orientation of the origins of
the celiac and superior mesenteric arteries relative to the aorta, a "cross-table" or lateral aortogram is considered an
essential view for the diagnosis of mesenteric disease. The AP view can be useful for visualizing key collaterals that
confirm the presence of a proximal mesenteric stenosis, such the arc of Riolan and the marginal artery of Drummond.
47. The most frequently employed criterion is a renal artery aneurysm repair in a female of reproductive age who is
currently pregnant or plans to become pregnant.
a. Symptoms of renal aneurysms may include frank rupture with hypotension and pain, flank pain, evidence of
embolization into the renal parenchyma, and hematuria. Renal artery aneurysms believed to be
symptomatic merit repair. For asymptomatic aneurysms, most authors have utilized a threshold of ≥ 2.0 cm
in maximal diameter. Saccular morphology and lack of calcification of renal artery aneurysms have not been
associated with rupture, so these should not influence the decision to operate.
48. Several variables have been linked to an increased probability of improved renal function with renal artery
revascularization, including high-grade stenosis, bilateral renal artery stenoses, resistive index < 0.8, and rapid
deterioration in renal function in the 3 months prior to stenting. Among these variables, it appears that a rapid
deterioration in renal function is most predictive.
49. A peak systolic velocity greater than or equal to 275 cm/sec in the superior mesenteric artery, greater than or equal
to 200 cm/sec in the celiac artery, or no flow signal (superior mesenteric artery and/or celiac artery) predicted a 70%
to 100% stenosis.
50. –

Lower Extremity Vascular Disease

1. –
2. Following the diagnosis of acute limb ischemia, a weight-based bolus of intravenous unfractionated heparin (100
units/kg) should be administered, followed by a weight-based continuous drip (18 units/kg/hr). Administration of
heparin leads to thrombus stabilization, prevents thrombus propagation, and has a vasodilatory effect.
3. “Blue toe syndrome,” most likely resulting from multiple emboli from an aortic source, thus CT angiogram of the
chest, abdomen, and pelvis should be obtained to best evaluate for the presence of aortic mural thrombus.
4. The Rutherford classification of acute limb ischemia describes the clinical characteristics and viability of a malperfused
limb. Stage I is a viable limb, which is not immediately threatened. There is no sensory loss or muscle weakness. There
are audible arterial and venous Doppler signals. Stage IIa is a marginally threatened limb that is salvageable and
requires prompt treatment. There is minimal sensory loss and no muscle weakness. There may be audible arterial
Doppler signals and there are audible venous Doppler signals. Stage IIb is an immediately threatened limb that is
salvageable with immediate revascularization. There is sensory loss, which involves more than just the toes, and there
is associated rest pain. There is mild or moderate muscle weakness. There are typically no audible arterial doppler
signals. There are usually audible venous Doppler signals. Stage III is a limb that is irreversibly damaged with major
tissue loss or permanent nerve damage. There is profound sensory (anesthetic) and muscle weakness (paralysis).
There are no audible arterial or venous Doppler signals.
5. The use of covered stents allows for immediate restoration of arterial flow utilizing endovascular techniques in clinical
scenarios where thrombolysis may be contraindicated (including recent surgery or hemorrhage).
a. In the distal external iliac artery, which is in an area of repetitive motion, a self-expanding stent should be
used.
6. Recent gastrointestinal bleeding is an absolute contraindication to the administration of thrombolytics, because even
catheter-directed infusion increases the risk of recurrent hemorrhage.
7. The decision to perform fasciotomies following reperfusion is based primarily on the clinical criteria, specifically tense
compartments with motor or nerve dysfunction. Additional indications include patients who cannot be reliably
examined following reperfusion, prolonged ischemia (greater than 6 hours), combined arterial and venous injuries
necessitating operative repair, reperfusion associated with arterial reconstruction, and concomitant crush injuries or
significant fractures
a. If compartment pressures are to be used with clinical findings, dynamic compartment pressures should be
used (mean difference between the arterial pressure and the intracompartmental pressure). Fasciotomy is
warranted if the difference between the intracompartmental pressure and the mean arterial pressure falls
to less than 40 mm Hg.
8. Myonecrosis may occur within hours following lower limb reperfusion with subsequent compartment syndrome,
leading to release of large amounts of potassium, myoglobin, and creatine phosphokinase. Myoglobinuria leads to
acute kidney injury via renal vasoconstriction, tubular cast formation, and direct heme protein-induced cytotoxicity.
Management includes aggressive fluid resuscitation, urine alkalinization with bicarbonate, and diuresis with mannitol.
Contrast-induced nephrotoxicity presents clinically 48 to 72 hours after administration of contrast.
9. Aneurysms in random locations at young age (i.e. tibial artery) consider ehler-danlos, which is associated with high
incidence of CAD at young age
10. Infected femoral pseudoaneurysms in drug abusers carry a high incidence of limb loss and require complete excision
and debridement.
11. Femoral pseudoaneurysms in patients who are anticoagulated after a coronary intervention are unlikely to
spontaneously resolve and require thrombin injection.
12. Popliteal artery aneurysm: Several randomized trials and a current meta-analysis have shown equivalence of open
and endo repair in anatomically suitable patients.
13. –
14. Although popliteal aneurysms can rupture, the main risk is thrombosis and limb loss. They should be repaired, even
when small, if the lumen has a thrombus burden of more than 50%.
15. For popliteal aneurysm repair, the tibial runoff is the most important determinant of stent graft patency following
endovascular repair. A seal neck of 15mm is adequate.
16. This situation is classic for cholesterol embolism syndrome: the blue toes (both feet) and renal failure are both due to
diffuse microscopic arteriolar occlusion by showers of cholesterol emboli (crystals of which can be seen on biopsy)
induced by endovascular manipulation.
17. Posterior knee dislocation mandates careful consideration for blunt popliteal artery injury. The mechanism of injury
to the popliteal artery is blunt shear force of the vessel, resulting in dissection and disruption of the intimal and
medial layers. Full vessel transection is uncommon. Pulse discrepancy mandates thorough evaluation with
angiography and repair. Angiography is the gold standard for identification of popliteal injury and historically was felt
to be mandated for all posterior knee dislocations regardless of signs of vascular trauma. With a normal pulse
examination, serial vascular examinations and protection of the popliteal from injury with external fixation is
appropriate in this setting.
a. After repair, antiplatelet therapy would be standard, but is not indicated in the absence of injury.
18. Gluteal compartment syndrome is an uncommon but morbid complication that can occur from prolonged positioning
or crush injury. Iatrogenic cases have been reported with obese patients and with the use of the dorsal lithotomy
position. Prompt identification and gluteal decompression is critical to prevent further complications of muscle
ischemia and rhabdomyolysis. The gluteal region has 3 compartments that require assessment: the gluteus maximus,
medius/minimus, and tensor fascial latta compartment. The medius and minimus muscles share a common fascial
compartment with the superior gluteal artery and nerve. The gluteal maximus compartment has the inferior gluteal
artery and nerve. Normal gluteal compartmental pressures are 13-14 mmHg and decompression should be
considered for values greater than 30 mmHg or if clinically suspicions and intermediately elevated pressures greater
than 20 mmHg. Decompression is done via the prone position through an expansile-type Kocher-Langenbeck incision.
19. Hard signs of acute traumatic limb ischemia include absent distal pulse, active bleeding, expanding hematoma, and
palpable thrill or bruit. This mandates further examination through imaging and direct arterial exploration.
Revascularization will be required to avoid amputation.
a. Although bypass with the contralateral saphenous vein may be optimal, patients with hypothermia,
coagulopathy, and acidosis require resuscitation and damage control maneuvers. Shunting is associated
with a low thrombosis rate and an amputation rate
b. PTFE should be avoided in a contaminated field
20. The pathophysiological mechanisms that contribute to the development of diabetic foot ulcers are primarily
neuropathic and include sensory neuropathy of Type A myelinated alpha fibers. Sensory neuropathy results in the loss
of protective sensation. Autonomic neuropathy (or sympathetic dysfunction) results in the shunting of blood from the
skin and the loss of oil and sweat gland function. This causes dry skin, which is at risk of cracks and fissures. Motor
dysfunction can lead to trophic changes in the leg and foot muscles, which alters the biomechanics of the foot.
Although diabetics with hyperglycemia are prone to diabetic foot polymicrobial infections, these are a result of the
neuropathic changes that allow ulcers to form and infection to occur.
21. Management of diabetic foot wounds requires a multifaceted approach. Chronic wounds require debridement to
promote healing and wounds closure with pressure offloading by either nonsurgical or surgical means. In the setting
of an acute infected diabetic wound, antibiotic treatment in addition to prompt debridement and drainage is also
necessary. When concomitant peripheral arterial disease is present, revascularization is needed. The method of
revascularization (open or endovascular) is dependent on a multitude of factors (comorbidities, targets, and conduit
availability). However, revascularization to the angiosome of the wound may be beneficial for limb-related outcomes.
a. The medial plantar branch of the posterior tibial artery supplies the angiosome for a dorsum of the first
metatarsal
22. Management of diabetic foot infections require source control and treatment of infection with debridement or
amputation and revascularization if indicated by ischemia.
23. Trials have demonstrated superiority of drug-coated balloons over plain balloon angioplasty in terms of primary
patency in lesions of the superficial femoral artery.
24. In DCB’s, the excipient aids in transfer of the paclitaxel from the balloon to the arterial wall. Once in the arterial wall,
paclitaxel diffuses through the intima to the media and adventia, where it is thought to have an antiproliferative
effect on smooth muscle cells as the primary mechanism for preventing restenosis
25. Most studies demonstrate increased embolization rates with atherectomy. A finding that is almost ubiquitous among
these studies is a low rate of bail out stenting for residual stenosis or dissection.
26. Although recent reports suggest that vascular groin infections, including those with exposed grafts, can be managed
with either tissue flap coverage or vacuum-assisted closure devices, optimal management generally includes excision
of all prosthetic material, debridement of infected soft tissues, followed by revascularization in those patients with
limb-threatening ischemia. Patient’s presenting with symptoms of rest pain, revascularization is indicated. Ideally a
redo bypass should be performed using autogenous saphenous vein. In the absence of autogenous conduit, the
options include either a redo prosthetic bypass tunneled outside of the infected field or a bypass performed with
cryopreserved saphenous vein.
27. Prosthetic conduit comprising polytetraflouroethylene has been shown to have intermediate-term primary patency
rates that are similar to those of an autogenous saphenous vein when used for above-knee bypass grafts. The patency
drops considerably for these grafts compared to an autogeneous saphenous vein when sewn to a below-knee target.
28. The differential diagnosis of claudication in young patients includes thromboangiitis obliterans, adventitial cystic
disease, popliteal artery entrapment, chronic exertional compartment syndrome, lower extremity trauma, infectious
embolism, fibromuscular dysplasia, vasculitis, middle aortic syndrome, and persistent sciatic artery.
a. Reduction of distal pulses occurred during stress maneuvers, can be seen in popliteal artery entrapment or
adventitial cystic disease. Adventitial cystic disease is classically associated with loss of distal pulses after
knee flexion (Ishikawa’s sign). CT or MR angiographic imaging of the lower extremities is useful for obtaining
objective information on anatomic changes and differentiating adventitial cystic disease from popliteal
artery entrapment. The popliteal artery is intermittently compressed in this patient with plantar flexion
thereby causing intermittent compression and subsequent claudication rather than acute thrombosis
29. External iliac artery endofibrosis can be seen in high performance cyclists and other athletes. Extreme hip flexion
leads to repetitive trauma to the external iliac artery secondary to the iliopsoas muscle or inguinal ligament in the
setting of high blood flow. It can manifest as leg claudication, leg cramping, numbness, and fatigue. Hyperflexion of
the cyclist’s thigh, which causes the external iliac artery to bend and places mechanical stress on the greater curve of
the artery, also contributes to chronic repetitive arterial injury. Patch angioplasty or interposition bypass grafting with
inguinal ligament release are associated with return to competitive activity and improvement in the post-exercise
ankle-brachial index (ABI).
30. During anterior exposure of the spine at the L4-L5 and L5-S1 levels ligation and division of the ascending iliolumbar
vein facilitates exposure of the L4-L5 level
a. Retrograde ejaculation occurs after injury to the sympathetic nerve plexus, not the parasympathetic.
b. The rectus abdominus muscle is retracted laterally, not medially, after a left paramedian fascial incision.
31. Intimal collagen deposition and disruption of internal elastic lamina is a description of intimal fibroplasia, a form of
fibromuscular dysplasia. Adventitial cystic disease, is characterized by mucin-containing cystic structures
(Proteohyaluronic-acid), and can affect the popliteal artery, iliac artery, radial and ulnar arteries, and peripheral veins.
Medial calcific sclerosis, or dystrophic calcification, is frequently seen in diabetes mellitus and renal failure patients.
Disorganized collagen fibers and rare collagen bundles are seen in classic-type Ehler-Danlos syndrome.
32. A persistent sciatic artery (PSA) is a congenital vascular anomaly resulting in atresia of the superficial femoral artery.
In the “complete” PSA type, the PSA continues into the popliteal artery, serves as the principle blood supply to the
lower extremity, and is most often associated with a hypoplastic common femoral and superficial femoral artery,
which ends at the adductor canal. In the “incomplete” type, the PSA is hypoplastic and is a continuation of the
hypogastric artery and courses through the sciatic foramen into the thigh. The superficial femoral artery remains the
principal supply to the lower extremity. The PSA is prone to atherosclerotic change, aneurysmal degeneration with
thromboembolism, and sciatic neuropathy from nerve compression. A pulsatile buttock mass can be appreciated on
physical examination on patients with PSA.

a.
33. The patient’s condition is most likely thromboangiitis obliterans, or Buerger’s disease. This is an inflammatory
vasculopathy that affects small- and medium-sized arteries and veins and is strongly associated with heavy tobacco
use. Most patients are between 20 and 40 years of age, and it is more common in males (M:F ratio, 3:1). Patients
typically present with claudication that can progress to critical limb ischemia. Complete tobacco abstinence is the
primary form of therapy.
34. Popliteal artery: It refers to symptomatic compression of the popliteal artery due to an abnormal relationship with
the medial head of the gastrocnemius muscle or a popliteus or fibrous band.

a.
35. Several risk factors for post-catheterization pseudoaneurysm have been identified, including larger sheath size,
punctures either proximal or distal to the common femoral artery, female sex, and anticoagulation. Although
asymptomatic pseudoaneurysms of less than 2 cm may be managed conservatively, treatment is indicated for
pseudoaneurysms that are larger, infected, or are causing significant pain, local compressive symptoms, or skin
necrosis.
36. Management strategy for intermittent claudication is directed at reducing the risk of cardiovascular morbidity and
mortality and improving overall functional status. Initial management of IC includes antiplatelet and statin therapy,
smoking cessation, and structured exercise. The exercise program should be prescribed as 30- to 45-minute sessions
at least 3 times per week, for 12 weeks. The intended benefit is the improvement of pain-free walking distance and
enhanced functional capacity. Although additional diagnostic evaluations may help delineate the anatomic pattern of
occlusive disease, revascularization is only indicated once these other measures have first been implemented and in
cases where the symptoms are severely lifestyle-limiting.
37. –
38. –
39. -
40. Tibial nerve courses through the deep posterior compartment. The posterior tibial artery is located in the deep
posterior compartment. The soleus muscle is located in the superficial posterior compartment. The superficial
peroneal nerve is located in the lateral compartment. The flexor hallicus longus is located in the deep posterior
compartment.
41. -
42. In HDS patients with concomitant CFA and CFV injuries, primary venous repair does not increase the risk of venous
thromboembolism and it has high primary patency rates. Military experience shows that in stable patient repair of
both the common femoral artery and the common femoral vein provides the best short- and long-term outcomes.
Ligation of the vein increases the incidence of chronic venous disease due to increased venous pressure. In order to
avoid poor long-term clinical outcomes, primary venous repair should be considered whenever is possible.
43. Vascular shunts are most effective in proximal extremity vascular injuries, such as those of the femoral and popliteal
vessels of the lower extremity. The most common complications of shunting are thrombosis and distal embolization.
Smaller vessels (such as tibials) are at highest risk for occlusion. Inadequate clearance of preexisting clot from the
inflow and outflow vessels and/or aggressive manipulation of the shunt itself renders the risk of thrombosis high. Risk
of thrombosis also increases significantly with shunt dwell time of greater than 8-12 h.
44. With graft site infection the most conservative treatment involves complete excision of the infected graft material,
followed by bypass through uninfected tissue.
a. In groin graft infection, a bypass through the obturator foramen is, as it achieves revascularization through
uninvolved tissue planes, avoids potential contamination of the contralateral graft limb, and does not
interfere with future groin wound management options, such as debridements or muscle flaps.
45. While mannitol, bicarbonate, and crystalloid infusion are useful adjuncts to diminish the sequelae of ischemia-
reperfusion injury and subsequent myoglobinuria, they do not provide initial benefit in actually treating an acute
compartment syndrome.
46. In the setting of combined arterial and venous injuries, particularly with a prolonged ischemia time, four-
compartment fasciotomy should be used liberally for limb salvage. This is especially true in the popliteal fossa where
concomitant arterial and venous reconstruction should be performed whenever feasible.
47. –
48. –
49. This patient has a classic neuropathic ulcer under the metatarsal head. It is also referred to as a "mal perforans" ulcer
(literally "bad penetration"). It may develop in the absence of significant arterial disease. The most obvious finding is
the accumulation of a large amount of fibrotic callus over the metatarsal head. The callus acts like a foreign body
under the weightbearing surface and contributes to the development of a pressure sore. Sensory neuropathy leads to
a loss of protective functions of the foot so that the development of the callus goes unnoticed. In addition, it is
believed that dysfunction of the intrinsic motor nerves of the foot results in changes in the shape of the foot that
favors ulcer formation. In particular, motor denervation contributes to the elevated arch and flexed position of the
toes ("clawed toes") that results in excess pressure on the metatarsal heads. The callus should be debrided to the
level of viable tissue. Repeated debridement is the rule, rather than the exception, because of the tendency of the
callus to recur. The formation of callus requires adequate blood supply and is a subtle reminder that revascularization
is unnecessary in most patients. In addition, the pressure over the metatarsal head must be reduced in order to
achieve healing. This can be accomplished with a variety of techniques including orthotics, total contact casting, and
making the patient non-weightbearing.

Venous and Lymphatic Disease

1. Patients undergoing surgical treatment of varicose veins including ligation of the greater saphenous vein at the
saphenofemoral junction, stripping, and multiple phlebectomies had significantly better health-related quality of life
scores, symptomatic relief, and satisfaction than patients only undergoing conservative therapy with compression
stockings. Furthermore, surgical management was more cost effective than conservative management. Although
injection sclerotherapy produced less benefit overall when compared to surgical management, it too was found to be
more cost effective than conservative management alone.
2. According to the manufacturer of endovenous ablation devices, the primary contraindication is active superficial
venous thrombus; however, concerns have been raised in patients with pacemakers, arterial insufficiency, GSV less
than 2 mm or greater than 15 mm, or those with tortuous GSVs.
3. Endovenous heat-induced thrombus (EHIT) after radiofrequency ablation or endovenous laser ablation (ELA) of the
GSV. Current classification criteria focus on the extent to which the thrombus extends into the deep venous system,
which can be used as a guide for management strategies.

a.
4. For solitary CFV injury, primary repair of venous injuries if a patient is hemodynamically stable and would tolerate
repair. Lateral venorrhaphy has been shown to have higher patency rates than bypass or interposition grafting.
5. Chronic venous insufficiency secondary to left iliac vein stenosis resulting from compression of the left iliac vein by
the overlying right common iliac artery. Duplex ultrasonography is a sensitive method used to identify a clinically
significant central vein stenosis with the following features suggestive: post-stenotic turbulence (mosaic appearance);
abnormal Doppler signal at stenosis; continuous flow with Valsalva; sluggish flow with no spontaneous variation; poor
augmentation and absent respiratory variation.
6. Severe form of venous thoracic outlet syndrome; specifically, primary axillary-subclavian vein thrombosis, which
results from chronic subclavian vein injury due to repetitive trauma at the anterior junction of the first rib and clavicle
(i.e., effort thrombosis or Paget-Schroetter syndrome). While percutaneous mechanical thrombectomy and catheter-
directed thrombolysis offers early success rates that approach 90%, early recurrence is common. Permanent
symptom relief and long-term patency are more likely to be achieved in patients who undergo first rib resection with
or without endovenous balloon venoplasty than in those patients whose rib is left intact.
7. Systemic thrombolytic therapy accelerates the resolution of PE, as evidenced by more rapid lowering of pulmonary
artery pressure, increases in arterial oxygenation, and resolution of perfusion scan defects balanced with the risk of
hemorrhage. Systemic thrombolysis is shown to be effective in reducing mortality and the recurrence of venous
thromboembolism balanced against a heightened risk of bleeding. Given the risk of major hemorrhage associated
with thrombolysis, current guidelines support the use of systemic thrombolysis for patients with acute PE associated
with hypotension (SBP <90 mmHg) and without high bleeding risk (grade 2B). The guidelines emphasize that “in most
patients with acute PE not associated with hypotension, we recommend against systemically administered
thrombolytic therapy (grade 1B).” As the evidence for the use of catheter-directed thrombolysis (CDT) is compared
with anticoagulation alone, CDT is of low quality compared with systemic thrombolysis and catheter-based treatment
(i.e., thrombectomy) without thrombolytic therapy. The 2016 CHEST guidelines suggest that systemic thrombolytic
therapy be used over CDT for those patient with acute PE who are treated with a thrombolytic agent (grade 2C).
However, patients who have a higher bleeding risk with systemic therapy and who have access to the expertise and
resources required for CDT are likely to choose CDT over systemic therapy. The same guidelines recommend against
the use of inferior vena cava filter for acute venous thromboembolism for patients treated with anticoagulation.
8. Pelvic congestion syndrome. Percutaneous coil embolization of the refluxing ovarian and internal iliac vein tributaries
(with or without adjunctive sclerosant) has become the standard of care for treatment yielding symptomatic
improvement in 50% to 80% of patients. In cases of pelvic venous congestion associated with iliiocaval obstructive
disease resulting from May-Thurner syndrome or nutcracker syndrome resulting from left renal vein compression, the
venous compression syndrome should be treated
9. Retroperitoneal sarcomas are the most common caval tumors encountered. Tumor resection in this case requires en-
bloc resection of the IVC. Management of the IVC with reconstruction or ligation remains controversial for those
patients with chronic IVC occlusion across series. In patients with partial obstruction, however, most surgeons would
favor reconstruction to decrease the risk of lower extremity edema and acute renal failure. Externally reinforced
(ringed) PTFE is favored over autogenous conduit to provide radial force that resists visceral compression, providing
up to 90% patency over 5 years.
a. Patch angioplastic repair of the IVC should be considered for those lesions requiring resection of less than
50% of the IVC with autogenous vein or bovine pericardial patch.
10. According to the tenth edition of the CHEST guidelines, distal DVT may be treated with anticoagulation or serial
imaging depending on patient characteristics (grade 2C). It is recommended that patients at high risk for bleeding be
followed with ultrasound surveillance. Symptomatic patients at high risk for propagation may be better treated with
anticoagulation. Risk factors for propagation include elevated D-dimer level, extensive thrombus burden, close
proximity to proximal veins, history of venous thromboembolism, no provoking factor, active cancer, and in-patient
status.
11. The rate of DVT during the peripartum period remains elevated at 0.2%, which is four times the rate of DVT in the
general population. This situation poses a number of challenges for the treating physician. Although rare, the
development of phlegmasia in this patient population is increasingly complex. Due to the limb-threatening nature of a
DVT, it is important to take action beyond continued anticoagulation. Tissue plasminogen activator (TPA) is a category
C medication in pregnancy and has very rarely been used in this patient population. In an effort to minimize radiation
and the potential harmful effects of TPA, venous thrombectomy remains a surgical option for the treatment of
extensive iliofemoral DVT.
12. Caval wall penetration from a previously placed inferior vena cava (IVC) filter.. Retrievable IVC filters have a higher
incidence of wall penetration and some experts have advocated for aggressive removal of these filters.
13. Iliofemoral DVT, the tenth edition of the CHEST guidelines recommends anticoagulation alone over catheter-directed
thrombolysis (grade 2C). Regarding the choice of anticoagulant, the CHEST guidelines recommend the use of low-
molecular-weight heparin over the novel anticoagulants and vitamin K antagonists (grade 2C).
14. Apixaban is contraindicated in patients with severe liver disease.
15. Patients with long-bone fractures requiring immobilization remain at a very high risk for the development of venous
thromboembolism. Low-molecular-weight heparin would be the best choice for DVT prophylaxis.
16. Factors that increase the risk of EHIT are large-diameter GSV, age, and increased levels of D-dimer at the time of
treatment. Classification of EHIT is based on the risk of thrombus propagation. EHIT level 1 is described as closure
with thrombus below the level of the epigastric vein. This is a normal finding after thermal ablation. Level 2 is closure
with thrombus extension flush with the orifice of the epigastric vein. This may be a normal finding, but signals a
possibility of further extension. It may require additional follow up in selected patients. Level 3 is closure with
thrombus extension flush with the saphenofemoral junction. This level may require anticoagulation in selected
patients with high thrombotic risk, but does not require any additional measures in the majority of patients. Level 4 is
closure with thrombus bulging into the common femoral vein (CFV). Closure with proximal thrombus extension
adherent to the adjacent wall of the CFV past the saphenofemoral junction is classified as level 5. The most
appropriate management of patients with EHIT levels 4 and 5 is anticoagulation until the thrombus retracts to level 3.
Level 6 represented closure with significant proximal thrombus extension into the CFV. This level should be
considered and managed as a provoked deep vein thrombosis requiring 3 month of anticoagulation.
17. lymphedema Tarda: Onset of lymphedema tarda is usually after age 35. Pathophysiological mechanisms of primary
lymphedema can be grouped in three broad categories: obstruction, reflux, and overproduction. Because the patient
has no signs or symptoms of venous disease, and the swelling is unilateral, the most likely mechanisms are
obstruction and/or reflux. Venous edema does not affect toes of the foot, and usually does not produce a positive
Stemmer sign
a. Noonan syndrome, which can include congenital lymphedema, and which manifests at birth.
18. Primary Lymphedema is classified based on the age of onset. Congenital lymphedema manifests within 2 years from
birth. Lymphedema praecox manifests between ages of 2 and 35 years. Lymphedema tarda has its onset at age of 35
or later. Secondary lymphedema is associated with infection, trauma or surgery.
19. Complex decongestive therapy includes an intensive reduction phase with manual lymphatic drainage (MLD), short-
stretch bandaging, exercise, and skin care education, followed by a maintenance phase with compression wraps, self-
MLD, and use of low pressure sequential pneumatic compression as needed. This is the best option for initial
management of severe lymphedema.
a. ** Rapid-inflation intermittent pneumatic compression devices are used for DVT prevention. High-pressure
intermittent pneumatic compression devices are indicated for treatment of peripheral arterial disease.
b. Elastic compression can be used in mild lymphedema, but is ineffective in severe lymphedema.
20. GSV ligation and stripping has been utilized with success for more than a century. However, due to the potential
morbidity and longer recovery time related to the procedure itself, the indication for GSV ligation and stripping has
been limited to patients who have a large, dilated, and tortuous incompetent saphenous vein and for the situations,
where the vein is located in close proximity to the skin, in which cases endovenous ablation is problematic.
21. Partial obstruction of saphenous vein after an episode of thrombophlebitis and tortuous and dilated saphenous vein
located in close proximity to the skin are potential contraindications for vein thermal ablation. The size of the great
saphenous vein has also been listed as a potential contraindication because of the risks of vein perforation in small
veins (less than 2 mm) and lower efficacy in large veins (greater than 15 mm).
22. Anticoagulation remains the mainstay treatment for acute deep vein thrombosis (DVT). In patients with iliofemoral
DVT who have a reasonable life expectancy, an onset of symptoms lasting less than 14 days, and a low risk of
bleeding, catheter-directed thrombolysis or pharmacomechanical thrombectomy are indicated in order to decrease
long-term DVT complications, such as post-thrombotic syndrome. In patients with DVT involving the popliteal vein
and/or any other more proximal deep veins, an inferior vena cava (IVC) filter is indicated if there are contraindications
to anticoagulation
a. Options include antivitamin K agents, apixaban, dabigatran, rivaroxaban, and edoxaban. While these oral
anticoagulants are recommended for patients with DVT who do not have active malignancy, patients with
cancer and DVT fare better if treated with low-molecular weight heparin (LMWH) for the first 3 months.
Dalteparin and enoxaparin are both FDA-approved LMWH agents.
23. Duodenal perforation by IVC filters is a rare but potential complication of IVC filters. Upper endoscopy is a useful
workup tool to rule out duodenal perforation by visualization of filter prongs in the duodenum lumen.
a. Laparotomy with cavotomy and patch angioplasty for filter removal is the most efficacious and durable
treatment option.
24. Patients with pelvic congestion syndrome (PCS) often present with chronic pelvic pain that can be associated with
dyspareunia, urinary urgency, and lower extremity painful varicose veins (nonsaphenous vein reflux). Women with
two or more children appear to have a higher incidence of PCS compared to nulliparous and those with one born
child. Symptoms are usually worse during menstrual cycles. A transabdominal ultrasound is the most complete initial
imagining workup for PCS. It is a low cost, safe, real time diagnostic modality. It is possible to confirm pelvic
varicosities, to measure parauterine and ovarian veins diameter and gauge its reflux, to investigate left renal and iliac
vein compression, and to rule out ovarian, pelvic, and iliac vein reflux.
a. Currently, the first line, initial treatment for pelvic congestion syndrome secondary to ovarian vein reflux is
left ovarian vein coil embolization with or without pelvic vein sclerotherapy.
25. Venous malformations are rare. They can cause a variety of symptoms depending on the organ and location affected.
Venous malformations may cause a localized coagulopathy. As a result, patients have elevated systemic levels of D-
dimer. This can be used to differentiate venous malformations from arteriovenous malformations or lymphatic
malformations.
26. Catheter-directed thrombolysis allows thrombus removal and preservation of valve function. Iliofemoral DVT is
associated with a high risk of postphlebetic syndrome that impairs. Catheter-directed thrombolysis was shown to
decrease the risk of postphlebetic syndrome and its severity compared to anticoagulation alone.
27. Placement of IVC filters without absolute indications is not cost effective.
28. The placement of permanent IVC filter in addition to anticoagulation in patients presenting with DVT decreases the
rate of PE but increases the rate of DVT and has no effect on survival or incidence of postphlebetic syndrome after 8
years of follow up.
29. –
30. Duplex ultrasound has become the standard method to evaluate venous reflux in both the deep and superficial
venous systems. Many maneuvers can be performed to elicit reflux in the venous system, including proximal and
distal augmentation, Valsalva, and 15-degree placement of the patient in reverse Trendelenburg. Toe up maneuvers
are typically used in arterial evaluation if patients are unable to walk on a treadmill for exercise-ABIs.
31. Perforating veins are now increasingly recognized to be a significant contributor towards the formation of venous
ulcers. Perforators can be treated surgically by a number of modalities: percutaneous thermal ablation, subfascial
endoscopic perforator surgery, open surgery, or sclerotherapy.
a. No role for treatment of perforators unless the clinical evaluation shows evidence of venous ulceration (C5
or C6).
32. Surgical treatment of greater saphenous veins in patients with symptomatic venous reflux disease can be
accomplished by a number of available modalities: thermal ablation, vein stripping and injection of cryoacrylate. All of
these modalities have been shown to be effective in the treatment of axial reflux. The newest technology is the
injection of cyano-acrylate as a method to close the vein.
a. CAE does not require tumescent anesthesia and this may contribute to decreased incidence of
postoperative ecchymosis
33. Venous outflow obstructions can be caused by external compression of the iliac veins or by intrinsic obstruction.
These lesions are poorly identified with cross-sectional imaging. IVUS has been beneficial in identifying lesions that
are otherwise missed by other modalities.
34. Chronic occlusion of inferior vena cava (IVC) has varied presentations ranging from an asymptomatic condition to
severe bilateral lower extremity edema, hyperpigmentation and venous ulcers. Endovascular recanalization with
iliofemoral stenting has now become the first line intervention for this debilitating condition. Angioplasty alone does
not provide durable results. Open reconstruction with femorocaval bypass is a significantly morbid procedure.
35. At initial evaluation, the venous leg ulcer should be debrided of all necrotic tissue and slough. This is important in
order to remove bioburden and to turn the wound from a chronic wound into an acute wound.
36. The most important aspect of treating venous leg ulcers is compression therapy. However, in order to reduce the
recurrence of the ulcer, the superficial system should be treated in patients with pathologic reflux of the great
saphenous vein. The preferred treatment is thermal ablation (laser and radiofrequency), but nonthermal techniques
using foam, glues, and mechanical-chemical treatments can be used. Ligation and stripping can also be performed,
but are not usually done because more invasive treatment and the thermal techniques are equally efficient.
Perforator ablation should only be considered for a pathologic perforator that is 3.5 mm in diameter, has reflux of
greater than 500 ms, and is beneath the ulcer bed or associated with a healed ulcer. Continuing compression is
important, but when the venous hemodynamics are corrected by ablating the superficial system, the risk for ulcer
recurrence is reduced significantly. An axillary vein valve transplant is rarely performed, and would only be considered
when all other treatment modalities for the superficial, perforator, and outflow iliac venous system have failed.
37. EHIT I, thrombosis to the level of the SFJ; EHIT II, extension into the deep venous system, cross-sectional area less
than 50%; EHIT III, extension into the deep venous system, cross-sectional area greater than 50%, EHIT IV, occlusion
of the femoral or popliteal vein. For patients with EHIT III and IV, most practitioners would anticoagulate.
Anticoagulation duration has not been established but most would follow CHEST guidelines for a provoked deep
venous thrombosis, and anticoagulate for 3 months. EHIT I is thought to be a benign self-limiting condition of no
clinical significance. Treatment for EHIT II is controversial; however, most practitioners would anticoagulate and/or
repeat an ultrasound at 1-2 weeks to observe for resolution.
38. With young age of the patient presenting with varicose veins, limb hypertrophy, and dermal capillary hemangiomas
(port wine stain) is consistent with Klippel-Trenaunay syndrome (KTS). Limb hypertrophy can be from increased bone
growth or soft-tissue mass. Patients with KTS have congenital venous anomalies and often have atresia and agenesis
of the deep venous system, valvular insufficiency, venous aneurysms, and the presence of embryonic veins. In
addition, abnormalities of the lymphatic system are often present. A complete assessment of the venous and
lymphatic anatomy is imperative and is performed with venography (conventional or 3D magnetic resonance) as the
ideal method to evaluate the entire venous system, which is mandatory before any interventions are planned to
reduce the complication rate. Lymphangiogram (lymphscintigraphy) complements the venogram. In addition, Duplex
ultrasonography is also performed. The mainstay of treatment for KTS is conservative management with compression
garments, education, multidisciplinary approach, and spacers for limb discrepancies. In patients who require surgery,
a patent deep system must be present before operating on superficial veins and venous malformations. Endovenous
ablation of the great saphenous vein is a standard therapy and is also utilized in appropriately selected patients
following a thorough investigation of the venous system in patients with KTS.
a. Parkes Weber syndrome is similar to KTS but is much rarer. It is distinguished from KTS by having arterial
venous malformations and also arterial venous fistulas.
39. –
40. Intermittent pneumatic compression (IPC) devices are useful for DVT prophylaxis, especially in orthopedic patients
and those in whom anticoagulation is contraindicated. Levels of prostacyclin and tissue plasminogen activators are
elevated by IPCs.
41. The term superficial accessory great saphenous vein (vena saphena magna accessoria superficialis) indicates any
venous segment ascending parallel to the GSV and located more superficially above the saphenous fascia, both in the
leg and in the thigh. The term anterior accessory great saphenous vein (vena saphena magna accessoria anterior)
indicates any venous segment ascending parallel to the GSV and located anteriorly, both in the leg and in the thigh.
One or more intersaphenous vein(s) (vena(e) intersaphena(e)) course obliquely at the calf to connect the SSV with the
GSV. A cranial extension of the SSV that communicates with the GSV via the posterior thigh circumflex vein is often
termed the vein of Giacomini.
42. Although surgical thrombectomy of iliofemoral thrombosis is not frequently performed in the United States, there are
a number of reports with very good long-term patency rates of about 80% and less postthrombotic symptoms than
treatment with anticoagulation alone.
a. Creation of an arteriovenous fistula increases the flow through iliofemoral veins and helps improve the
patency.
43. The femoral vein is the most commonly injured lower extremity deep vein. Unstable patients should have venous
ligation, although there is a higher incidence of pulmonary embolism. Synthetic grafts are the last option for venous
repair. The initial choices are lateral venorrhaphy or a paneled graft.
44. The sural nerve is a sensory nerve formed by branches of the common peroneal and tibial nerves. It provides
sensation to the lateral ankle, lateral heel, and lateral foot. The nerve typically travels in close proximity to the short
saphenous vein in the lower third of the calf, laterally along the Achilles tendon. Sural nerve anatomy, however, can
be variable. Injury to the sural nerve with endothermal ablation is not rare and can cause paresthesia or dysesthesia
in the region it innervates.
45. he most common patterns of recurrence after surgical ligation and stripping include neovascularization and recurrent
reflux at the saphenofemoral junction. The most common patterns of recurrence after endothermal ablation relate to
recanalization of the great saphenous vein and/or reflux in an accessory saphenous vein. Perforator vein reflux can be
seen after treatment with either modality.
46. Varicose veins are the most common manifestation of primary chronic venous insufficiency. Varicose veins are
defined as tortuous, prominent vein greater than 3 mm in diameter and that are not associated with discoloration of
the overlying skin.
47. The group at highest risk of recurrent DVT is patients with active malignancy
48. Compression of the left renal vein as it passes between the superior mesenteric artery and the aorta. This is known as
the "Nutcracker Syndrome" (NCS). Clinical features of this syndrome include abdominal pain, pelvic congestion, gross
or microscopic hematuria, proteinuria, orthostatic intolerance, and others. Left renal vein is typically 5- to 9-cm long
and drains into inferior vena cava between T12 and L2. In its distal part, it travels in a plane between the anterior
aspect of abdominal aorta and the posterior aspect of the proximal segment of superior mesenteric artery (SMA). The
SMA origin is typically at a right angle to the aorta, it proceeds in an anterior direction for 4 to 5 mm before travelling
caudad, thus preventing the compression of left renal vein. The main tributaries of left renal vein are the left gonadal
vein, left ureteral vein, the capsular veins, the lumbar veins, suprarenal vein and inferior phrenic vein. Compression of
left renal vein causes increased pressure in the vein and development of collateral pathways, which cause the
associated symptoms.
49. Neovascularization is known to occur at the saphenofemoral junction after open surgical crossectomy with great
saphenous vein stripping. The classic ultrasound finding is that of tortuous veins (small or large) with a mosaic pattern
on color flow duplex ultrasound, and in communication with the femoral vein in the groin.
a. At the time of surgery, placement of non-biologic barriers has reduced the risk of neovascular channels at
the saphenofemoral junction, following ligation and stripping in a randomized controlled trial. Re-operation
usually requires redo surgery, foam sclerotherapy, endovenous ablation, or a combination of these
techniques.
b. These channels have endothelium, but are primitive channels with incomplete layers of the venous wall,
lacking both clearly defined intimal and adventitial layers and medial and adventitial elastic tissue.
50. This patient is at the highest risk for perioperative DVT with advanced age, obesity, abdominal surgery, and active
cancer. Combination prophylaxis with mechanical and pharmacological methods is recommended.
a. patients with malignancy undergoing major surgery, or those undergoing major orthopedic surgery, should
receive pharmacological prophylaxis both in hospital and for a month after discharge. Subcutaneous
unfractionated heparin (UFH) for prophylaxis should be administered TID
51. Vein which is dilated and noncompressible with echolucent material in the lumen has ultrasound signs of acute
venous thrombosis. A vein that has has echogenic material similar to the surrounding tissues and the adventitia of the
vein, which is typical of the chronic thrombus.
52. In select patients with an acute iliofemoral DVT who are relatively young, active, and wish to be aggressive after
understanding the risks, thrombolysis may be considered.
53. In patients with acute isolated distal DVT of the leg and (i) without severe symptoms or risk factors for extension, it is
recommended to obtain serial imaging of the deep veins for 2 weeks over anticoagulation (Grade 2C), and (ii) with
severe symptoms or risk factors for extension, anticoagulation is preferable over serial imaging of the deep veins
(Grade 2C).
a. In the absence of anticoagulation, propagation of calf vein thrombosis to the popliteal vein or higher is
observed in some patients with initially isolated calf deep vein thrombosis

Vascular Medicine

1. LMWH is a mixture of smaller molecules, which diminishes the affinity of neutralizing cells and proteins to bind with
them. This in turn eliminates the dose-dependent mechanism of action of unfractionated heparin. After
subcutaneous injection, nearly 90% of LMWH is bioavailable. LMWH is metabolized almost exclusively in the kidneys.
2. In patients with protein C deficiency, initiation of anticoagulation induces a transient hypercoagulable state because
of the shorter half-life of protein C. This clinically manifests as skin necrosis, most commonly of the breasts, buttocks,
thighs, and penis.
3. Tissue plasminogen activator (t-PA) is a product of endothelial cells predominantly, but also vascular smooth muscle
cells as well as mast cells, neuronal cells, monocytes, and fibroblasts. Relatively little t-PA circulates in the free
(unbound) form, with most being bound in a complex form, predominantly with plasminogen activator inhibitor-1
(PAI-1). In its unbound form, the half-life is 2 to 3 minutes, which is extended to 5 minutes when t-PA is bound to PAI-
1, but this reduces its potency.
4. In setting of HIT  Bivalirudin and argatroban are both direct thrombin inhibitors that are effective anticoagulants.
Bivalirudin is metabolized by the kidneys and argatroban is metabolized by the liver.
5. Hypofibrinogenemia is a feared complication of lytic therapy, even if theoretically isolated to a limb, and patients
should be monitored for its development. If the fibrinogen levels drop below a certain threshold (typically less than
100 mg/dl), immediate cessation of the lytic agent is appropriate. Further decline in fibrinogen mandates
administration of product to correct the iatrogenic coagulopathy. Cryoprecipitate contains concentrated levels of
fibrinogen, factor VIII, von Willebrand’s factor, and factor XIII.
6. Cigarette smoking is associated with endothelial cell damage and altered endothelial function. Studies have shown
that cigarette smoking increase platelet adhesion and permeability of endothelial surfaces to fibrinogen. Smoking
decreases nitric oxide availability and impairs vascular tone.
7. C. pneumonia is the bacterium that has been most often associated with atherosclerosis in both clinical and
experimental settings. C. pneumonia has been found to correlate with the severity of peripheral artery disease, an
increased risk of myocardial infarction, and stroke.
8. First-line pharmacologic agents include nicotine replacement, buproprion, and varenicline. All three have been shown
to be more effective than placebo. In a randomized study, buproprion (antidepressant) resulted in higher abstinence
rates than nicotine patch or placebo. The most common adverse effects are insomnia and dry mouth. Smokers
typically start the medication 2 weeks prior to a quit date, with a starting dose of 150 mg/day for three days, titrating
to a dose of 300 mg/day in divided doses.
9. This patient has mildly limiting claudication. First-line therapy is medical management with a supervised exercise
program. Pentoxifylline provides only modest improvements in claudication. Cilostazol is contraindicated in this
patient, because it is a phosphodiesterase inhibitor and may increase mortality in patients with heart failure.
10. Blood pressure goals for the treatment of hypertension in patients with peripheral artery disease are BP’s under
140/90. Serum low-density lipoprotein should be reduced to under 70mg/dL in this population. And Hb-A1c < 7.0.
11. ACE inhibitors block ACE conversion of angiotensin I to angiotensin II. They are the best choice as a second line agent
for treatment of hypertension in diabetic patients and in those with chronic kidney disease.
12. High-intensity statin therapy is indicated in patients with evidence of peripheral artery disease and mesenteric
disease regardless of baseline low-density lipoprotein levels. Atorvastatin 40 mg or 80 mg or rosuvastatin 20 mg or 40
mg are considered high-intensity statin therapy.
13. In patients with hypercoagulable state, with history of DVT, they should be anticoagulated for life
14. Macrophages within the intima engulf oxidized low-density lipoproteins (LDLs) and become laden with lipids, resulting
in foam cells. Foam cells within the intima appear as fatty streaks, an early histologic sign in pathogenesis of
atherosclerosis. This early process is reversible.
15. FVL mutation is a point mutation that results in insensitivity of Factor V to activated protein C. It is the most common
hereditary cause of VTE, although only about 5% of FVL heterozygotes will develop a VTE in their lifetime. The initial
treatment for acute VTE in FVL heterozygotes is the same as that for the general population.
16. Vascular surgery patients have an increased risk of perioperative cardiac complications compared to the general
population due to a high incidence of significant coronary artery disease and left ventricular dysfunction. The Revised
Cardiac Risk Index (RCRI) is a common risk model used to estimate the risk of perioperative cardiac events in patients
undergoing noncardiac surgery. There are six independent predictors of major perioperative cardiac complications.
These risk factors are high-risk type surgery, including vascular surgery and any open intraperitoneal or intrathoracic
procedures; history of ischemic heart disease; history of heart failure; history of cerebrovascular disease; diabetes
mellitus requiring treatment with insulin; and preoperative serum creatinine greater than 2.0 mg/dL. Patients with
moderate or high risk should be considered for preoperative stress testing if their baseline functional capacity is poor
or unknown. Studies have shown that the RCRI underestimates the risk of perioperative cardiac events in patients
undergoing vascular surgery
a. left ventricular systolic dysfunction is five times more common in patients with vascular disease compared
with matched cohorts
17. According to the ACC/AHA 2007 guidelines, aortic and other major vascular surgeries, as well as peripheral artery
surgery, are considered high-risk procedures with estimated perioperative cardiac death or myocardial infarction of
greater than 5%. Carotid endarterectomy is considered a moderate-risk procedure, along with head and neck surgery,
intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery. In these procedures, the risk of
perioperative cardiac death or myocardial infarction is about 1% to 5%. Low-risk surgeries include ambulatory
surgery, endoscopic procedures, superficial procedures, cataract surgery, and breast surgery.
18. According to the American College of Cardiology/American Heart Association (ACC/AHA) 2014 guidelines, patients
with an elevated risk of a perioperative cardiovascular event should undergo pharmacologic or exersize stress testing
based on their functional status.
19. Symptoms of alcohol withdrawal syndrome start within the first 24 to 48 hours after withdrawal and can peak
between the third and fifth postoperative day. Serious complications that may develop are delirium tremens and
grand mal epileptiform seizures. Delirium tremens is characterized by fever, tachycardia, hypertension, tremors,
diaphoresis, hallucinations, disorientation, agitation, and urinary incontinence. Patients known to be at risk should be
administered prophylactic doses of benzodiazepines throughout the entire perioperative period to prevent the
development of alcohol withdrawal syndrome.
a. Most common cause of confusion and agitation in the postoperative period is hypoxia.
20. Giant cell arteritis (GCA) should be suspected in individuals older than 50 years who present with new-onset
headache in the presence of systemic inflammation. Women are affected 2 to 4 times as often as men.
a. Diagnostic criteria include 50 years of age or older at the onset of disease; new onset headache; temporal
artery abnormality; elevated erythrocyte sedimentation rate; and abnormal artery biopsy. At least 3 of the 5
criteria must be present to make the diagnosis of GCA.
b. In addition to new onset headache and tenderness over the temporal artery, patients also present with
generalized constitutional symptoms (fatigue, weight loss, fever), jaw claudication, or ocular symptoms,
such as decreased vision, diplopia, and amaurosis fugax. Up to one fifth of patients can develop permanent
vision loss. Treatment with steroids should be initiated when GCA is suspected.
21. Pregnancy creates multiple prothrombic conditions due to hormone-related induction of clotting factors as well as
the anatomic compression of the left iliac vein by the gravid uterus. Pregnant women are five times more likely than
age-matched counterparts to develop venous thromboembolism, and the risk appears to be higher in post-partum
women than in pregnant women. Pulmonary embolism is rare; however, VTE remains a leading cause of maternal
death. Women with known prothrombic conditions are more likely to suffer antepartum venous thromboembolism,
and most of these patients will have the factor V Leiden mutation.
a. Low-risk thrombophilia patients can be closely followed; however, high-risk thrombophilia patients should
receive prophylactic LMWH throughout the pregnancy as well as into the post-partum period.
22. For VWD patients undergoing surgery, a preoperative plan must be in place to control bleeding. Desmopressin
(DDAVP) has been shown to be effective in most variants of VWD; however, the gold standard of treatment of VWD
bleeding remains the replacement of the von Willebrand factor as well as the factor VIII for which the molecule acts
as a chaperone. Intermediate purity VWF/FVIII or Haemate P is the most widely studied replacement product.
a. All postoperative patients receiving VWF/FVIII replacement postoperatively should have regular factor VIII
testing, since risk of thrombosis with elevated levels
23. Antiphospholipid antibodies (aPLa) and the antiphospholipid antibody syndrome (APLAS) are common causes of
acquired hypercoagulability; the two most common types are lupus anticoagulants (LA) and anticardiolipin antibodies
(aCL).
a. Most experts agree that there is no role for anticoagulant prophylaxis in asymptomatic patients with
circulating antibodies; however, clinical thrombosis necessitates anticoagulation. The high rate of
recurrence warrants lifelong anticoagulation. Deep vein thrombosis is the most common manifestation of
APLAS, although arterial thrombosis is also common.
b. If history of thrombosis, give lifelong therapeutic anticoagulation
24. Homocysteine metabolism involves two enzymatic pathways, and derangements of either can lead to
hyperhomocysteinemia. The MTHFR mutation is most commonly associated with hyperhomocysteinemia; however,
with folate supplementation these patients can frequently normalize their homocysteine levels. It is estimated that
elevated homocysteine confers a 2- to 8-fold risk elevation for myocardial infarction and stroke, and this risk appears
to be higher in women than in men.
a. Even the normalization of homocysteine does not reduce the risk of venous thromboembolism and
peripheral arterial thrombosis, even in patients who are appropriately treated.
25. Of the five drugs typically used to treat HIT (lepirudin, argatroban, danaparoid, bivalirudin, and fondaparinux) only
the direct thrombin inhibitor argatroban is approved in the US for the treatment of HIT (although others are
frequently used). Warfarin is typically started when the thrombocytopenia has resolved.
a. Supratherapeutic INR (greater than 3.5) has been associated with an increased risk of warfarin-related
necrosis, and therefore low-dose warfarin is favored over loading dose warfarin (10 mg or greater).
26. Patients with suspected HIT benefit from immediate risk stratification, and the 4T score (thrombocytopenia, timing of
platelet count fall, presence of thrombosis, other causes of thrombocytopenia) is widely used and has an excellent
negative predictive value.
a. Thrombocytopenia in the absence of anti-PF4-heparin antibodies is never HIT. Anti-PF4-heparin enzyme
immunoassays have excellent negative predictive value, and a negative test effectively rules out HIT.
i. As many immunoassays detect many types of immunoglobin (only IgG activates platelets),
confirmatory testing is typically conducted via functional assay (i.e. serotonin-release assay or
heparin-induced platelet-activation test);
27. Heparin-induced thrombocytopenia (HIT) syndrome, which is an immunologically mediated event in which antibodies
are created during exposure to heparin. These antibodies are activated by the heparin-bound platelet factor 4
macromolecule complex. Platelet factor 4 is a cytokine, which is produced by megakaryocytes and released from the
alpha-granules of activated platelets during platelet aggregation. Platelet factor 4 promotes coagulation by
moderating the effects of heparin-like molecules. Platelet factor 4 is released and available to bind to cell surface
glycosaminoglycans and heparin. Heparin itself is a mixture of glycosaminoglycans that bind to antithrombin III and
Xa, resulting in increased activity of antithrombin III.
28. Procedural risk factors that increase bleeding risk include duration of thrombolysis therapy longer than 48 hours,
serum fibrinogen levels less than 100 mg/dL, and an activated partial thromboplastin time greater than 100 seconds.
29. C/S Hypercoagulable after warfarin: This condition is treated by immediate cessation of warfarin, intravenous vitamin
K, fresh frozen plasma, and use of an alternative anticoagulant once the patient’s INR is no longer therapeutic.
30. A prior history of allergic-like reaction to gadolinium-based contrast media does not increase the risk of a similar
reaction to iodinated contrast media.
31. The CLEVER trial compares objective and subjective outcomes in patients randomized to optimal medical care (a
standard home walking program and cilostazol), endoluminal arterial stenting, and a supervised exercise program.
Data published from this trial showed superior improvement in treadmill walking performance in patients randomized
to a supervised exercise program compared to those who had both optimal medical care and stenting.
32. Typically, symptoms present somewhere between 3 and14 days after the initiation of heparin therapy, but can
present sooner if the patient had been exposed to heparin previously. Both unfractionated and low-molecular-weight
heparins have been associated with HIT.
a. This syndrome is caused by a heparin-induced IgG antibody that initiates platelet aggregation, depleting
serum platelets and promoting thrombosis in its most severe form.
33. Argatroban, an FDA-approved agent for anticoagulation in patients with heparin-induced thrombocytopenia, acts as a
direct thrombin inhibitor that irreversibly binds to the active thrombin site resulting in inhibition of fibrin formation,
activation of clotting factors V, VIII, XII, activated protein C, and platelet aggregation. Its action is independent of
antithrombin III. The drug is metabolized by the liver and no dose adjustments are needed for renal impairment.
Because argatroban is a direct thrombin inhibitor, coadministration with warfarin produces a combined effect on the
laboratory measurement of the INR.
a. Since it falsely elevates INR, the argatroban should only be stopped after INR > 5, at which point warfarin
should be maintained
34. The patient has phlegmasia cerulean dolens, which is a limb-threatening condition in which venous outflow is
significantly compromise by massive thrombosis of the major outflow veins of the lower extremity. There is a 3:1
predilection favoring left-sided phlegmasia over the right. The recent development of mechanical thrombolysis
techniques allows for rapid thrombolysis and restoration of venous drainage. Mechanical thrombolysis in
combination with catheter directed lysis has become the treatment of choice in patient with phlegmasia cerulean
dolens.
35. Three morphologic types of primary aortic tumors (polypoid, intimal, and adventitial)
a. Polypoid tumors have a focal attachment to the intimal surface with growth extending into the lumen of the
vessel, such as a myxoma. Hence, embolization is common with these tumors. Intimal tumors have fewer
projections into the vessel lumen; rather, they grow along the endothelial surface. These tumors tend to
lead to large-branch vessel occlusion. Adventitial tumors grow outward and invade surrounding structures.
b. Greater than 70% of primary aortic tumors are of the intimal type, with equal distribution throughout the
aorta. Resection of the mass with interposition grafting is the treatment of choice. However, in 60% of the
cases, metastatic disease is noted at the time of diagnosis and mean survival in this circumstance is around
14 months
36. Renal cell carcinoma is the most common malignancy that exhibits intracaval thrombus
a. Thrombus is usually seen in larger renal cell carcinomas, greater than 4.5 cm.
37. –
38. Atheroembolism occurs when cholesterol embolizes from a proximal atherosclerotic plaque. This can cause livedo
reticularis, toe gangrene, and pain. The posterior tibial and dorsalis pedis arteries are commonly preserved with
palpable pulses but occlusion of the digital arteries.
39. The profunda femoral artery provides the arterial perfusion to the soft tissue of the thigh. Manipulation of the
profunda femoral artery during creation of the proximal anastomosis can cause compromise.
40. –
41. Intermittent (or sequential) pneumatic compression therapy uses inflatable cuffs for the calf, ankle, and foot.
a. The cuffs empty the plantar venous plexus. This reduces the venous leg pressure, increasing the
arteriovenous pressure gradient. Long-term effects include enhanced angiogenesis and collateral formation
in response to the generation and release of nitric oxide, tissue factor pathway inhibitor, and endogenous
tissue plasminogen activator. It has been shown to relieve ischemic rest pain and improve wound healing in
patients with non-reconstructible arterial occlusive disease. The greatest effect has been demonstrated in
the popliteal artery, with increased flow after use of intermittent pneumatic compression therapy.
42. –
43. Hemodynamically stable patients in atrial fibrillation should have pharmacologic heart rate control and chemical
cardioversion with electrolyte repletion and adjustment of volume status, if necessary.
a. Hemodynamically unstable patients should have urgent electric cardioversion. If the patient has been in
atrial fibrillation for more than 48 hours or for an unknown length of time, anticoagulation and monitoring
for embolic events should be considered.
44. Studies failed to demonstrate any mortality-related benefit of prophylactic coronary revascularization even in high-
risk patients with multiple risk factors and/or multi-vessel disease. Medical therapy is sufficient for many patients
with NSTEMI in the perioperative setting, especially those patients whose only indicator is elevated troponin. STEMI is
an emergency in the nonoperative and operative setting, this is the only setting where coronary revascularization has
a mortality benefit.
45. Preventing ventilator-induced lung injury: ressure-control ventilation to reduce peak airway pressures is frequently
used. Inspiratory times often are increased in this mode of ventilation to increase alveolar recruitment.
Transpulmonary pressures are kept at less than 30 cm H2O using tidal volumes less than 6-8 ml/kg ideal body weight.
Such low tidal volumes cause decreased CO2 clearance, resulting in respiratory acidosis. This is well tolerated if pH is
greater than 7.2 and there is no concern for cerebral edema.
46. Patients maintained on mechanical ventilation average 1%/day risk of VAP. This risk is highest in the first week of
intubation.
a. Age greater than 80 years is a preoperative predictor of postoperative pneumonia, as is smoking within the
past year, but the risk of this is less than 1% overall.
47. The major cause of postoperative renal failure after vascular surgery is perioperative hypotension and ischemic injury
leading to acute tubular necrosis. Such renal failure is a marker for increased postoperative mortality.
48. There is no survival benefit when using albumin instead of crystalloid for fluid resuscitation in critically ill patients,
despite the theoretic benefit of intravascular volume expansion and reduced third spacing.
49. In heparin-induced thrombocytopenia (HIT), after the discontinuation of heparin results in normalization of platelet
counts the risk of thrombosis remains high up to 4 weeks afterward. Limb ischemia resulting in amputation has been
reported in many cases after HIT. Arterial rather than venous thromboses are more common in vascular patients due
to arterial injury.
50. –
51. Two platelet activation routes are thought to result in thrombosis. Without direct vessel damage, platelet activation
may occur via tissue factor activation with factor VIIa generation and the activation of platelets. Alternatively,
subendothelial collagen may be exposed by the disruption of vessel integrity—circulating platelets directly bind
exposed collagen with collagen-specific glycoprotein Ia/IIa surface receptors. This adhesion is strengthened further by
von Willebrand factor (vWF), which is released from the endothelium and from activated platelets. vWF forms
additional links between the platelets' glycoprotein Ib/IX/V and the collagen fibrils. This localization of platelets to the
extracellular matrix promotes collagen interaction with platelet glycoprotein VI. Binding of collagen to glycoprotein VI
triggers a signaling cascade that results in activation of platelet integrins. Activated integrins mediate tight binding of
platelets to the extracellular matrix. This process adheres platelets to the site of injury. Once the platelet plug has
formed, coagulation protein assembly begins via intrinsic and extrinsic pathways. During platelet activation, granules
also release their contents (calcium and serotonin), and membranes are exposed that are rich in receptors for factors
Va and VIIIa, fibrinogen, and vWF. Plasma prekallikrein is a serine protease that complexes with high-molecular-
weight kininogen during contact activation of the intrinsic pathway of the coagulation cascade. It is cleaved by factor
XII to produce kallikrein. Tissue factor (TF) and Factor II (prothrombin) are components of the extrinsic pathway of the
coagulation cascade. TF is expressed on tissue-factor-bearing cells (i.e., stromal fibroblasts and leukocytes) and form
an activated complex (TF-FVIIa) with Factor VIII following damage to the blood vessel. Factor II (prothrombin) is
activated to thrombin by the prothrombinase complex with thrombin subsequently activating other components of
the coagulation cascade, such as Factor V and Factor VIII.

a.
52. Risk factors for contrast induced nephropathy include diabetes mellitus, hypertension, chronic kidney disease, older
age, and intra-arterial administration. Several therapies have been suggested to mitigate the risk of CIN, including oral
hydration, volume expansion using intravenous normal saline or sodium bicarbonate, possibly administration of N-
acetylcysteine, statins, and withdrawal of metformin, ACE inhibitors, and angiotensin-receptor blockers.
53. The development of an atherosclerotic plaque includes the adhesion of blood leukocytes to the active endothelial
monolayer and directed migration into the intima. Many of these leukocytes mature into macrophages, which take up
lipid, becoming foam cells. There is a net increase in the number of smooth muscle cells in the intima, both from
proliferation of resident smooth muscles cells and from migration of smooth muscle cells from the media to the
intima. These smooth muscle cells produce extracellular matrix macromolecules. Both smooth muscle cells and
macrophages can die within the plaque, increasing the overall lipid core of the plaque

Vascular Diagnosis

1. While duplex ultrasound scanning is the first choice for most venous imaging applications, venography (infusion
venography) is an appropriate alternative or a useful complement to venous duplex scanning for several indications:
(1) diagnosis of deep vein thrombosis when duplex ultrasound is non-diagnostic or not technically feasible; (2) when
duplex ultrasound is negative despite a high clinical suspicion for DVT or calf vein thrombosis; (3) evaluation for
venous stenosis, anatomic entrapment or other causes of venous hypertension; (4) evaluation for venous
malformations; and (5) preoperative evaluation for tumor involvement or encasement.
a. Direct access of deep veins of the leg may be used for ascending venography, but access of a superficial foot
vein is less invasive and potentially easier for the patient and surgeon than other options. Use of a
superficial tourniquet directs the contrast filling into the deep veins.
b. Popliteal vein access may be used for ascending venography, but this technique may fail to detect calf vein
thrombosis.
2. Early restoration of brain perfusion with intravenous recombinant tissue-type plasminogen activator (rtPA; alteplase)
improves outcomes after ischemic stroke. The presence of intraparenchymal hemorrhage is a contraindication to rtPA
use and prompt imaging is needed. A non-enhanced CT scan (NECT) can definitively exclude parenchymal hemorrhage
and can assess for other rtPA exclusion criteria, including widespread hypo-attenuation, a sign of a large infarct.
3. Magnetic resonance imaging with diffusion-weighted imaging (DWI) is the most sensitive and specific imaging
technique for acute infarction, far better than CT or any other MRI sequence.
a. It can identify small cortical lesions and small deep or subcortical lesions
4. TEE is excellent for the evaluation of suspected aortic dissection. It is portable, yields a diagnosis within minutes, and
is easily performed in the emergency department if trained users are available. The sensitivity of TEE has been
reported to be high. Esophageal intubation usually requires procedural sedation, which may have risks in
hemodynamically unstable patients. TEE has a wide field of view and high resolution. It can detect entry tear sites,
false lumen flow (or thrombosis), involvement of the arch or coronary arteries, presence and severity of aortic
valvular regurgitation, and the presence of pericardial effusion. Intimal dissection flaps can be identified. Color
Doppler clearly demonstrates flow in the true and false lumens. False lumen thrombosis or intramural hematoma can
be seen.
5. Exercise normally increases systolic pressure and decreases peripheral vascular resistance. Limb blood flow is
increased, augmenting the pressure gradient across stenotic lesions. Moderately severe arterial stenosis may not be
associated with a trans-lesion pressure gradient at rest, but exercise may produce a drop and claudication symptoms.
This is most common with an iliac artery stenosis.
a. Criteria to confirm a hemodynamic response consistent with claudication include: (1) 20 mm Hg or greater
drop in ankle pressure; (2) 20% or more drop from baseline ABI; or (3) drop in (absolute) ankle pressure to
less than 60 mm Hg, with more than 3 minutes required to recover. If exercise reproduces symptoms but
the ankle pressure (or ABI) remains normal or unchanged, PAD is not the cause of symptoms and another
etiology should be sought.
6. –
7. The duplex ultrasound diagnostic criteria for internal carotid artery (ICA) occlusion include:
1) Absence of flow by color, power and pulsed Doppler;
2) Low resistance flow in external carotid artery (“internalization”);
3) Relatively high resistance (“externalized”) flow in common carotid artery (CCA);
4) Transient flow reversal (“pre-occlusive thump”) in distal CCA;
5) Thrombus or plaque-filled ICA lumen on B-mode image;
6) Asymmetry in CCA waveforms and velocities between the patent and presumed occluded carotid arteries.
8. Fluorodeoxyglucose, abbreviated [18F]FDG or 18F-FDG, is a radiopharmaceutical used in positron emission
tomography (PET). 18F-FDG uptake is seen in tissues with increased intracellular glucose metabolism, which can
include infectious and inflammatory processes.
9. In the setting of calcific medial Calcinosis (ABI > 1.4), if TBI > 0.6, the patient likely has good arterial perfusion
10. Indocyanine green (ICG) angiography uses a near-infrared fluorophore to detect tissue perfusion without
radiation. Laser-assisted fluorescence angiography (LAFA) captures a real-time image of the target area with an
infrared camera. Imaging systems have software to analyze ICG intensity for the captured area and selective regions
of interest. LAFA can reliably detect tissue perfusion in skin and subcutaneous tissue of targeted areas. The
technology has a limited tissue penetration of 5 mm and does not provide information on muscle perfusion.
a. Other methods include: Transcutaneous oxygen monitoring and hyperspectral imaging
11. Acute hypotension with bradycardia following intravenous administration of iodinated contrast media indicates a
vasovagal reaction. Intravenous atropine, not epinephrine, is recommended if the patient remains symptomatic
despite leg elevation of and rapid infusion of IV fluids.
a. Intravenous or intramuscular epinephrine should be used for treatment of anaphylactoid reactions:
hypotension with tachycardia, laryngeal edema, and bronchospasm refractory to albuterol treatment.
12. In evaluating for compression of the celiac artery from the median arcuate ligament, imaging is typically performed
during suspended respiration to
a. Imaging during the expiratory phase will accentuation of celiac artery compression.
13. A maximum intensity projection (MIP) view in the sagittal plane best depicts this compression of the celiac artery in
patients with suspected median arcuate ligament syndrome
14. Perforator veins connect the deep and superficial venous systems, penetrating through the deep fascia overlying the
muscle. Venous reflux due to valvular incompetence is best demonstrated with duplex scanning in the upright
position. Reflux in the common femoral vein and the saphenofemoral junction may be elicited with increased intra-
abdominal pressure using a Valsalva maneuver, but release of distal pneumatic cuff compression is a more
reproducible method and the cuff release method can be used for evaluation of venous segments more distally in the
limb. Perforator reflux is present when outward flow of greater than 0.5 seconds is demonstrated.
a. However, the cutoff value of 1 second for abnormally reversed flow (reflux) in the femoral and popliteal
veins and of 0.5 seconds for the great saphenous vein, small saphenous vein, tibial, deep femoral, and
perforating veins.
b. Re-entry perforators are perforating veins connected to a chain of varicose veins. They may or may not
show reflux. Pathologic perforator veins have reflux, are 3.5 mm in diameter or larger and are near a healed
or open ulcer.
15. Symptoms of left leg swelling and “bursting” pressure in the calf with exercise are typical for compression of the left
common iliac vein (May-Thurner syndrome). With exercise and increased limb blood flow, the restriction of venous
outflow results in venous hypertension. Appropriate noninvasive diagnostic tests to consider when non-thrombotic
iliac vein obstruction is suspected include CT venography, magnetic resonance venography (MRV), or duplex
ultrasound of the pelvic venous structures. Venography and intravascular ultrasound (IVUS) are used to confirm the
diagnosis prior to intervention.
a. Although lymphedema can cause limb swelling, it does not usually cause discomfort with exercise and
characteristically extends onto the foot.
16. Lymphedema should be suspected in a patient with limb swelling that involves the feet and toes. Lymphoscintigraphy
is the primary imaging modality for confirmation of the diagnosis of lymphedema and to define lymphatic anatomy.
Lymphoscintigraphy utilizes the lymphatic transport system of moving proteins from the interstitial space into the
venous system. Colloids with radioisotope labels, such as sulfur colloid labeled with technetium-99m, are injected into
the interstitial space. They are transported through the lymphatics to regional lymph nodes.
a. Intradermal injection is the standard technique, as the highest concentration of lymphatics is in the dermis.
17. A spectral waveform that shows continuous venous flow with no respiratory variation is for more central venous
obstruction.
a. Refluxing veins will have normal phasicity with respiration.
18. If waveform shows pulsatile venous flow. Pulsatile venous flow may be seen in patients with pulmonary hypertension
or right heart failure.
19. Veins occluded with acute thrombus are dilated (the vein diameter will usually be larger than the adjacent artery),
noncompressible, and hypoechoic. With chronic deep vein occlusion, the intraluminal contents of the vein no longer
contain hypoechoic thrombus. The material is more fibrotic and the vein tends to be small and echogenic.
20. A history of prior allergic reactions to other antigens, such as shellfish or dairy products, is unreliable in determining
an individual patient’s risk for the development of an allergic-type reaction to intravenous contrast.
a. Nephrogenic systemic fibrosis (NSF) is a systemic fibrosing disease primarily involving the skin and
subcutaneous tissues but also known to involve other organs. The disease was first noted to occur
predominantly in patients with end-stage chronic kidney disease and was subsequently associated with
exposure of gadolinium-based contrast agent to patients with advanced renal disease. NSF has only been
reported in patients with impaired renal function, either due to chronic kidney disease, acute kidney injured
superimposed on chronic kidney disease, or in some cases acute kidney injury without underlying chronic
kidney injury.
b. If GFR > 40 it is okay to use Gadolidium-based contrast
21. Ectopic gas within the excluded aneurysm sac, periaortic fluid, and tethering and bowel wall thickening of the
adjacent duodenum are more common findings in patients with aortoenteric fistulas (direct extravasation in the
bowel lumen is rare)
22. Carbon dioxide, when injected as a bolus, displaces blood. X-ray attenuation is reduced. The gas is therefore negative
contrast agent for digital subtraction angiography (DSA). Because of its lack of renal toxicity and allergic potential,
CO2 may be the preferred contrast agent for patients with renal insufficiency or prior contrast allergy. Carbon dioxide
can be used as a contrast agent for aortography, detection of bleeding, renal transplant arteriography, venography,
arterial and venous interventions, and endovascular aneurysm repair. Its use is contraindicated in the thoracic aorta,
coronary arteries, and in the cerebral circulation, where even small amounts of residual undissolved gas could cause
complications. Gadolinium is poor as a fluoroscopic contrast agent, and is associated with nephrogenic fibrosis in
patients with renal impairment.
a. Non-ionic, iso-osmolar agents are least nephrotoxic type of iodinated contrast agents, but are still
associated with risk of contrast-induced nephropathy, especially in patients with pre-existing renal
insufficiency and diabetes.
23. Wire artifact can develop as a result of age-related vessel elongation.
a. Care must be exercised in interpreting images with stiff wires in place. If a focal stenosis is seen in a
tortuous artery, especially near a branch point, artifactual stenosis should be considered
24. Expansion of an aneurysm sac after EVAR is presumptive evidence of the presence of an endoleak.
a. A type II endoleak may not be seen on CT angiography early in the arterial phase of contrast distribution.
Contrast transit through the collateral pathways that connect with the aneurysm sac takes longer than the
time for contrast density to peak in the aortic lumen. Re-imaging the area of interest after additional delay
(when circulating contrast is in the venous phase) can allow contrast to enhance the endoleak.
25. Clinically available gadolinium (Gd)-based MR contrast agents can be characterized by their distribution: those that
distribute quickly throughout the extracellular space and those that remain intravascular (blood pool agents).
Gadofosveset is an example of a blood pool agent. It is used as a contrast agent in MRA to evaluate arterial occlusive
disease. Following intravenous injection, gadofosveset binds reversibly to serum albumin, resulting in
macromolecular gadolinium (Gd[III]) complexes that do not readily cross the vascular endothelium. Thus, they have
longer vascular residence times than non-protein binding contrast agents. This allows for longer image acquisition
times, better signal-to-noise ratio, and improved image resolution. Because albumin-bound gadolinium complexes
remain intravascular for extended periods, gadofosveset enhances both arteries and veins in delayed imaging. Thus,
gadofosveset can have poor discrimination of arteries and veins.
26. –
27. –
28. On carotid US the blue color along the outer wall of the carotid bulb (proximal ICA) results from low velocity helical
flow patterns and reversed flow direction caused by the diverging-converging geometry of the carotid bulb. These
flow patterns are associated with low shear forces which may contribute to eventual wall-thickening and formation of
atherosclerotic plaque.
29. Velocity measurements obtained during duplex scanning are calculated using the Doppler equation: V=(∆f C)/(2 f
cosθ) where V is the calculated blood flow velocity, ∆f is the Doppler frequency shift, C is the propagation speed of
ultrasound, f is the frequency of the transmitted ultrasound, and θ is the angle between the ultrasound beam and the
vessel wall. The cosines of 60 and 0 degrees are 0.5 and 1.0, respectively. Therefore, since the cosine is in the
denominator, PSV measurements taken at 0 degrees will be lower than those taken at 60 degrees.
a. Acoustic shadowing may interfere with transmission of ultrasound, but it will not have an effect on the
magnitude of PSV measurements.
30. No respiratory variation or response to Valsava with lower extremity venous duplex, suggests proximal obstruction,
secondary either to common or external iliac vein deep vein thrombosis or to mechanical obstruction, such as in the
case of May-Thurner syndrome. In presence of caval or bilateral iliac vein occlusions, the waveforms in bilateral
femoral veins depict loss of respiratory variations.
31. A complete venous duplex scanning examination for chronic venous disease must include good vessel visibility,
compressibility, venous flow assessment with measurement of duration of reflux, and venous flow augmentation
maneuvers.
a. Compressibility is the most important component of venous duplex scanning whenever thrombosis is
suspected.
32. Magnetic resonance venography for diagnosis of venous TOS has comparable sensitively and specificity of venous
duplex, but is much more costly and time consuming and thus is not recommended as a first-line diagnostic tool.
33. The first test in a patient with suspected venous thrombosis should be ultrasound. Ultrasound will define the
superficial and deep venous systems; evaluate the compressibility of the common femoral, deep femoral, femoral,
and popliteal veins; and evaluate for flow, phasicity, and augmentation.
34. The renal aortic ratio compares the peak systolic velocity in the suprarenal abdominal aorta with that measured in the
renal artery. A renal aortic ratio (RAR) ≥ 3.5 is commonly used as a threshold value to identify a ≥ 60% stenosis, which
is a hemodynamically significant stenosis.
a. Peak systolic velocities greater than 180 cm/s are consistent with a stenosis that is less than 60%. An end-
diastolic velocity of greater than 150 cm/s suggests a stenosis of greater than 80%.
35. The appropriate frequency for color Doppler operation is highly depth dependent. When shallower than 1 to 2 cm,
higher frequencies result in stronger color Doppler signals. If deeper than 3 cm, especially when sensitivity is an issue,
the lowest possible operating frequency should be used to ensure adequate sensitivity.
36. –
37. Interpretation of transcranial Doppler studies is dependent upon knowledge of the window used for obtaining the
Doppler waveform, the depth from which the waveform was obtained, and the expected direction of flow within the
particular artery. The transtemporal window is used to examine the middle cerebral, anterior cerebral, and posterior
cerebral arteries, as well as the terminal intracranial internal carotid artery. The middle cerebral artery is imaged at a
depth of 30-60 mm and demonstrates antegrade flow towards the probe. The terminal internal carotid artery is
imaged at a depth of 55-65 mm and normally demonstrates bidirectional flow. The anterior cerebral artery is imaged
at a depth of 60-80 mm and normally demonstrates retrograde flow away from the probe. The posterior cerebral
artery is imaged at a depth of 60-70 mm and demonstrates antegrade flow towards the probe.
a. Vasospasm is diagnosed by elevations of mean velocities. Normal mean velocities in the vessels visible
through the trans temporal window are less than 60 cm/second. Vasospasm of the middle cerebral artery is
defined as a mean velocity greater than 120 cm/second. Vasospasm of the anterior cerebral artery is
described as a mean velocity greater than 130 cm/second without evidence of vasospasm in the middle
cerebral artery. A mean velocity of greater than 110 cm/second in the posterior cerebral artery indicates
vasospasm

b.
38. In this arrangement of the Doppler equation, V is the calculated blood flow velocity parallel to the vessel wall, where
f"D" is the Doppler frequency shift, 𝐶 is the propagation speed of ultrasound in tissue, F is the frequency of the
transmitted ultrasound, and θ is the angle between the ultrasound beam and the vessel wall.
a. Since the cosine function changes more rapidly at larger Doppler angles and approaches zero at 90 degrees,
the Doppler frequency shift becomes very small when the angle of insonation is not maintained less than 60
degrees. Thus, system sensitivity is reduced and errors in the calculated flow velocity increase with Doppler
angle.
b. Using the Doppler equation to calculate angle-corrected velocities, larger angles result in higher calculated
flow velocities.
c. The "aperture effect" results in decreasing calculated velocities as the angle decreases. This effect is
produced because the focused ultrasound beam encounters the flow stream at a range of angles, not just
the single set angle. Since these other angles tend to be smaller than the set Doppler angle, they result in
lower calculated velocity values. The reflection of ultrasound at the vessel wall-blood boundary tends to
increase at smaller Doppler angles.
39. Renal resistive index (RRI) is a simple parameter that can be derived from a renal ultrasound Doppler spectrum. The
index describes the percentage reduction of end-diastolic blood flow (Vmin) in the investigated vessel (interlobar
artery in that particular study) in relation to maximal systolic blood flow (Vmax): resistive index = (Vmax)/Vmax. It is
considered as a marker of downstream vascular impedance. A high resistive index is found with intra-parenchymal
kidney disease, including changes from glomerular sclerosis, tubulo-interstitial disease, and arteriolosclerosis.
40. –
41. –
42. "To and fro" flow is used to initially identify perforating veins, which are distinguished by a very stereotypical signal
seen from perforating arteries.
43. Carotid body tumors (CBTs) are rare neoplasms that develop within the adventitia of the medial aspect of the carotid
bifurcation. The carotid body originates in the neural crest and is responsible for acute adaptation to fluctuating
concentrations of oxygen, carbon dioxide, and pH. Most are sporadic in etiology but familial type is more common in
younger patients. The rare hyperplastic form is seen primarily in patients who have chronic obstructive pulmonary
disease (COPD) or cyanotic heart disease. Carotid body tumors are slow growing and present most commonly as an
asymptomatic palpable neck mass in the anterior triangle of the neck. The tumors may present with a nerve palsy
(pain, hoarseness, dysphagia, Horner syndrome, or shoulder drop) if they involve the hypoglossal, glossopharyngeal,
recurrent laryngeal, or spinal accessory nerve, or the sympathetic chain. The carotid body is highly vascularized by
branches of the ascending pharyngeal artery, itself a branch of the external carotid artery.
a. The Shamblin classification is used to stage carotid body tumors. Type I lesions are small and can be
dissected in the periadventitial plane. Type II partially surround the carotid artery. Type III tumors encircle
the carotid bifurcation. Most type II and III lesions require carotid resection and interposition graft
placement.
b. Carotid body tumors are treated with either surgery or radiotherapy depending on the presence or absence
of other paragangliomas and the patient's age and health status. Preoperative imaging is necessary to
evaluate the extent of the disease and its multiplicity. If catacholamine levels are elevated, an evaluation for
adrenal pheochromocytomas should also be performed. If detected these tumors should be removed prior
to the carotid surgery.
c. Surgical treatment is the mainstay for most tumors and can be associated with significant morbidities,
especially with large Shamblin III tumors (greater than 5 cm). Radiation is usually reserved for patients who
have poor medical conditions, elderly patients, or patients with recurrent tumors.
i. Pre-operative embolization of carotid body tumor can reduce operative blood loss and is usually
reserved for large tumors exceeding 4 cm in size.
44. If there is severe intracranial internal carotid occlusive disease, peak systolic velocities in the internal carotid artery
are decreased while the rapidity of systolic upstroke is maintained. There is increased resistance to flow, and
therefore, diastolic flow is reduced.
45. Cystic adventitial disease is a rare cause of intermittent claudication. It typically presents in middle age (40-50 years)
and is more common in men than women (5:1). Typical findings on duplex ultrasound include extra-luminal
compression of the popliteal artery by the adventitial cyst, which will appear anechoic or hypoechoic, with no color
flow.
a. Catheter-based angiography will show a “scimitar sign” if the cyst is eccentric or an “hourglass sign” if the
cyst is concentric.
46. Late manifestations of deep venous thrombosis (DVT). The vein wall is thickened and highly echogenic; it has
diminished caliber, marked collateralization may also be present as a late finding associated with previous venous
thrombosis
47. The most widely accepted measure of renal resistance is calculation of the parenchymal resistive index. Resistive
index is calculated as follows: (PSV-EDV)/PSV. A normal RI, indicating healthy renal parenchyma, is a value <0.8.
48. Increasing the pulse repetition frequency will increase the sampling rate of the pulsed Doppler and reduce or
eliminate the aliasing artifact, so the systolic peaks of the waveforms will fit on the velocity scale. This can also be
achieved by increasing the Doppler angle or using a lower frequency transducer.
a. Pulsed wave Doppler instruments determine blood flow velocity by taking intermittent "samples" of the
flow; the rate of this sampling is the pulse repetition frequency or PRF. The upper limit of the Doppler shift
frequency that can be detected accurately by this process is called the Nyquist limit, which is commonly
defined as PRF/2 or one-half of the PRF. Aliasing is an artifact of Doppler flow detection that occurs when
the Doppler frequency shift exceeds the Nyquist limit. When aliasing occurs in a spectral waveform, the
velocity information is displayed improperly and the systolic peaks are "cut off" at the top of the velocity
scale and appear below the baseline as flow in the reverse direction.
49. -
50. –

Radiation Safety

1. Radiation cataracts: While classically considered a deterministic effect of radiation exposure to greater than 2 Gray of
radiation, new evidence suggests that radiation-induced cataracts may occur at lower doses, especially in those
exposed to higher doses more frequently. It appears that there is both a deterministic as well as a nondeterministic
effect that leads to their development. Radiation-induced cataracts appear on the posterior capsule of the lens, which
is different than typical cataracts.
2. The absorbed dose provides a measure of deposited energy measured in gray (Gy) or milligray (mGy) per unit of mass.
One gray is equivalent to an energy deposition of one Joule per kilogram (J/kg) of tissue.
a. The effective dose corrects for the different sensitivity of various tissues by multiplying the absorbed dose
by a tissue weighting factor as well as correcting for the type of radiation to which the tissue is exposed
using a radiation weighting factor (WR). It is a calculated not a measured dose. It should be utilized to assist
in radiation protection planning and not in predicting individual patient cancer risk.
3. Scatter radiation that emanates from the patient is the main source of radiation to the operator and staff in an
interventional suite.
4. Geometric magnification is produced when the patient is placed close to the X-ray tube and the distance to the image
intensifier is increased. This increases both the patient’s entrance skin dose as well as increasing scatter radiation.
This should be avoided whenever possible. While electronic magnification can increase beam energy, this type of
magnification is the preferred modality. Fluorography (e.g., digital acquisitions) generate much higher radiation doses
than fluoroscopy. Utilizing fluoroscopy looping allows a fluoro run to be repeated in the same way a digital
subtraction run would be however the dose is much lower. Collimation reduces both patient skin dose as well as
scatter radiation and should be used whenever possible. High frame rates increase total radiation doses during cine
fluoroscopy as well as during acquisition runs and should be used only when absolutely necessary.
5. Hand injection acquisition requires the operator to remain closer to the X-ray tube during the acquisition phase of
imaging and thus exposes them to higher amounts of scatter radiation.
a. Stepping back or leaving the room during acquisition runs significantly decreases operator radiation
exposure as radiation dose drops off exponentially with increasing distance from the x-ray tube source
(1/r2). Pulsed radiation settings compared to continuous fluoroscopy generates lower doses of radiation and
thus lower exposure.
6. Collimating images to include only the desired structures decreases scatter radiation and improves image quality and
should be used whenever possible. The use of rapid frame rates improves image definition and resolution at the
expense of substantial increased radiation doses and should be used sparingly.
7. The threshold for skin injury begins at 2 Gray at which transient erythema may occur. This develops within several
hours of exposure. Permanent epilation typically requires 7 Gray of exposure and does not present for several weeks
after exposure. Dermal atrophy results from 10 Gray of exposure and is a late consequence of exposure with
telangiectasia formation occurring after similar exposure and lag time. Skin ulceration occurs after exposure to
greater than 10 Gray.
8. –
9. Deterministic effects of radiation are effects that occur at a specific threshold dose of exposure. Skin injury is the
most commonly reported deterministic effect of fluoroscopic procedures.
10. Radiation scatter levels decrease in proportion to the inverse squared distance from the irradiated patient volume.
11. The use of “last image hold” is required for all fluoroscopic equipment regulated by the US Food and Drug
Administration.
12. Pulsed fluoroscopy decreases the exposure of radiation and also decreases blurriness of the image from patient
motion. However, if the pulse rate is increased to 30 pulses/sec, the radiation dose becomes nearly equivalent to
continuous fluoroscopy.
13. By increasing the distance between the operator and the patient and table, the operator will receive much less of the
scattered rays.
14. Patient obesity is a risk factor for higher radiation dose and this should be mentioned during the consent process.
15. In the first weeks of pregnancy a dose as small as 100 mGy can be lethal for an embryo.
16. Lead should be at least 0.5 mm and ideally 1 mm in pregnant operators. Pregnant operators should step 6 feet away.
17. Peak skin doses of 5 to 10 Gy are associated with transient erythema in the first 2 weeks after exposure, followed by
dyspigmentation, edema, and hair loss during the period from 2 weeks to 10 months.
18. Limitation of radiation dosage to prevent cataracts: 20 mSv per year averaged over 5 years, but not to exceed 50 mSv
in a single year
19. Obesity increases tissue reactions from radiation exposure because higher doses are required to penetrate the
increased tissue mass. A number of medications, including many chemotherapeutic agents, potentiate the effects of
radiation. Genetics disorders such as ataxia telangiectasia (a mutation in a DNA repair gene), Fanconi anemia,
xeroderma pigmentosum, Gardner syndrome, and dysplastic nevus syndrome are associated with an increased
sensitivity to radiation, as are diseases such scleroderma, lupus, rheumatoid arthritis, hyperthyroidism, and diabetes
mellitus.
20. The locations of irradiated skin in order of decreasing radiation sensitivity are the anterior surface of the neck, flexor
surfaces of the extremities, trunk, back, extensor surfaces of the extremities, scalp, and, least sensitive, palms of the
hands and soles of the feet.
21. Radiation telangiectasia: It is associated with estimated peak skin doses of greater than 5Gy and rarely develops
earlier than 1 year after exposure. It can increase in extent and severity for up to 10 years after development.
22. The recommendation for dose limit during pregnancy for the fetus is 5 mSv.
23. Recommendation is for the use of lead with a thickness at least 0.5 mm
24. The use of gantry angulation is known to increase the risk of radiation scatter, received by the operator. Cranial
angulation appears to increase scatter at a rate higher than caudal angulation. This is because in cranial radiation the
X-ray source is brought higher and in closer proximity to operators compared to caudal views where the X-ray tube is
moved further away from the operator. When the operator is standing on the right side of the patient, Left anterior
oblique angulation appears to increase scatter to the operator at a higher rate than the right anterior oblique
angulation. This is again because the X-ray tube is brought closer to the operator in LAO views but moved farther
away from the operator in RAO angles.
25. Minimizing patient dose typically lowers operator dose because the operator is mainly subjected to scatter radiation
from the patient. Digital acquisition runs generate much higher doses than fluoroscopy and utilizing techniques like
fluoro looping can limit the overall dose and therefore the scatter radiation. Horizontal and vertical collimation are
known to decrease the radiation scatter by decreasing the field of view, thus narrowing the radiation beam and
scatter. The detector should be as low above the patient as safely possible. This decreases scatter because it
minimizes the source to detector distance. Thus, less energy is required to obtain an image of similar quality obtained
with the detector higher and farther from the patient. When the overall dose is less, then the scatter to the operator
is also less. Additionally, the placement of the detector close to the patient allows absorption of the scatter by the
detector itself. Raising the table height decreases overall patient skin dose because the patient’s skin is farther from
the X-ray tube and the dose at the patient drops off by 1/r2 as distance increases from the source. However, if the
table is raised, scatter radiation to the operator is increased because more of the operator is exposed to X-rays that
are refracting off the bottom of the table and are not attenuated through the patient. Similarly, magnification
increases radiation exposure to the patient but actually decreases scatter to the operator because magnification
decreases the field of view and therefore the scatter is decreased. Despite the fact that lowering the patient and
using magnification may decrease operator exposure, it is widely accepted that these are poor practices and should
not be employed because they significantly increases patient dose.
26. Knowledge of best practices through education can decrease the patient radiation dose index (peak skin
dose/reference are Kerma)
27. High-dose digital acquisition runs are a large source of radiation dose to the patient and scatter to the room
personnel. Limiting fluoroscopy time and using pulsed fluoroscopy decreases radiation dose to both the patient and
operator compared to continuous fluoroscopy and longer fluoroscopy times. Collimation decreases scatter radiation
by limiting the field of view. Fixed imaging systems appear to significantly increase the radiation exposure as
compared to mobile units. The increase in radiation is likely due to a larger image receptor size and the ability to run
at higher continuous and peak power levels.
28. CTA with fluoroscopy image fusion road-mapping in patients undergoing FEVAR/BEVAR. They found a significant
decrease in procedural time and use of contrast.
29. The distance factor especially in consideration to high-dose digital acquisition runs is the most important factor in
decreasing scatter for the surgeon.
30. The reference air kerma is the radiation dose measured at the interventional reference point. This offers a rough
estimate of the air kerma at the patient’s skin and includes both fluoroscopic and angiographic exposures.
a. Geometry factors, such as changes in angulation, can distribute the dose over a wider field of skin exposure
and changes in the table height may overestimate or underestimate the dose received.
b. Fluoroscopy time is not part of the reference air kerma measurement.
31. The reference air kerma is a dose metric that is displayed on the screen following an endovascular procedure and it
serves as the best approximation of patient skin dose.
a. The Kerma area product is a measure of the total output of the machine and is readily apparent on the
monitor upon completion of the procedure. It is the best metric of total radiation exposure.
32. The following are recommendations for proper protocol for radiation exposure: Any cumulative absorbed dose to the
skin equal to or greater than 2.0 Gy (200 rads) shall be noted in the patient’s medical record and reviewed by the
Radiation Safety Committee. The facility shall maintain records for 5 years of the cumulative fluoroscopic exposure
time used and the number of spot films for each examination. The record shall reflect the patient identification, type
of examination, date of examination, and operator’s name. If cumulative doses of more than 5 Gy are recorded,
fluoroscopist follow up is requested by the Radiation Safety Committee.
33. Stochastic and deterministic effects are biologic changes induced by radiation. Stochastic effects include changes in
cells that can cause a neoplasm and heritable changes in reproductive cells. Ionizing radiation can induce a change in
the genetic material of a single cell that may initiate development of a neoplasm. This can occur at any dose. At low
doses, the likelihood of inducing those changes necessary to cause the effect is very small. This probability increases
with increasing dose.
34. There is a latent period between irradiation and diagnosis that may range from 2 years to decades. Doses in excess of
200 mGy can induce cancers and the likelihood increases as the dose increases.
a. Erythema is a deterministic effect, which means that changes must occur in many cells before the effect is
seen. For this to occur, a certain threshold dose must be reached and the severity increases as the dose
increases. There is always a long delay between exposure and diagnosis of cancer.
35. Dermal necrosis is not an early reaction to radiation injury. It occurs several weeks to months after the exposure and
requires doses greater than 15 Gy. The development of telangiectasias and dermal atrophy are late findings (greater
than 40 weeks after exposure) of radiation injury. Dermal atrophy usually recovers after doses between 5 to 10 Gy
but telangiectasias and permanent induration and skin thinning can occur after doses greater than 10 Gy. Radiation
dermatitis from hand exposure usually presents with scaling skin and discoloration from the knuckles to the
fingertips. Eye damage results from lens opacities after acute doses in excess of 1 Gy. Cataracts that impair vision can
occur at doses greater than 5 Gy.
36. Medical co-morbidities and medications can increase a patient’s susceptibility to radiation injury (i.e., actinomycin D),
certain autoimmune disorders and some genetic states.
37. Increased relative risk of developing malignancy (leukemia, oral cavity, esophagus, stomach, colon, lung, breast,
ovary, urinary bladder, thyroid, liver, non-melanoma skin, and nervous system) as a result of radiation exposure.
Patients who undergo routine CT scans for postoperative surveillance after EVAR are at additional risk for acquiring
new solid organ malignancy due to the inherent radiation exposure. The risk is more pronounced in younger patients,
women and those exposed to contrast-enhanced CT scans.
38. In its most simplistic term, stochastic effect refers to the development of solid cancers and leukemia due to exposure
to ionizing radiation. It is not dose dependent and can occur months to years after the exposure. The effective dose,
or ED, is the sum of the absorbed dose by various organs weighted by tissue factors based on their radiosensitivity.
a. Referance Air Kerma, Flouroscopic Time, KAP, and ESD all describe deterministic effects.
39. –
40. –
41. Scatter radiation that contacts the interventionalist’s head, upper body, eyes, and thyroid have already been
attenuated through the patient and are less concentrated than those X-rays that hit the fluoroscopic table and then
are deflected to the interventionalist’s lower legs.
42. –
43. Regulations mandate that all individuals other than the patient must be protected using a 0.5 mm lead equivalent to
protect parts of the body struck by the useful beam.
44. Doses from previous procedures to the same body area be summed over a 6 to 12 month period. Interventional
procedures with a cumulative skin dose greater than 15 Gy to a single skin field over a period of 6 months to 1 year is
considered a sentinel event, thus should be further investigated and followed-up.
45. –
46. –
47. Procedural efficiency can translate to lower fluoroscopic times. This is the major determination of radiation exposure
during endovascular aneurysm repair (EVAR).
48. Radiation-induced effects at the cellular level include damage to both double-stranded and single-stranded DNA.
a. One of the most damaging effects of high levels of radiation is hydrolysis of water, which produces free
radicals.
49. Prolonged fluoroscopy with a cumulative dose > 1,500 Gy to a single field. “Cumulative dose” is defined as a dose
given within a period of 6 months to a year. A “single field” is defined as the location on the skin through which
fluoroscopic bean is directed, regardless of the projection.
50. The recommended peak skin dose threshold for internal investigation and reporting is 3Gy.